EQUIPMENT DEMONSTRATION

→ Use the mode switches in the oximeter real panel to set the language, averaging mode, patient mode, ... and there could be perfusion problem...

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EQUIPMENT DEMONSTRATION

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NATIONAL NEONATOLOGY FORUM

1. RADIANT WARMER OBJECTIVE

:

Upon completion of this section the participant should 1. know the parts of a warmer 2. be able to demonstrate the working of the warmer. 3. know the dangers associated with its usage and should be able to manage minor equipments maintenance. PARTS : Bassinet - Quartz rod - Skin probe - Air probe - Control panel - Heater output WORKING : i) Connect to mains ii) For prewarming keep heater output to maximum. iii) Place baby iv) Connect probe v) Read temperature on display vi) Adjust heater output - If below 360C- High - If between 36-36.50C-Medium - If between 36.5-37.50C-Low - If >37.50C-Remove baby/Switch off warmer. vii) Measure temperature 1/ 2 hourly X 2 hours & then 2 hourly. CLEANING & DISINFECTION - Glutaraldehyde 2 % - Soap/detergent } Once daily DOS & DONTS :

i) ii) iii) iv) v) vi) TROUBLE SHOOTING i) ii) iii) SIDE EFFECTS & DANGERS • • • •

Check temperature ½ hourly/2 hourly Ensure warm feet Ensure probe is connected Do not leave baby unattended. Ensure side walls are fastened up Ensure adequate clothing in case of electricity failure

MAINTENACE

Calibration Annual maintenance Contract

i) ii)

Check fuse Check plug Check cords Increased insensible water loss Fluid intake must be tailored to meet demands Hyperthermia Hypothermia

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2. PHOTOTHERAPY UNIT OBJECTIVE

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PARTS

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WORKING

:

CLEANING

:

DOS & DONTS

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Upon completion this section the participant should 1. know the parts of a phototherapy unit. 2. be able of understand the functioning and demonstrate the working of a phototherapy unit 3. be able to place a baby under phototherapy unit Tubes Number -6 Color -Blue/White Watt -20 Irradiance -4-8 uw/cm2/nm (minimum) Duration -3 months Wavelength -420-460nm Distance <45 cms i) Connect to mains. ii) Switch on the unit & check that all tube lights are working iii) Place baby naked only with the napkin on iv) Cover the eyes v) Change position frequently vi) Increase fluid intake ƒ Breast feed frequently ƒ Spoon/Gavage – Inc. by 20 ml/kg/day vii) Provide continuous phototherapy Glutaraldehyde 2% o Soap/Detergent i) Cover eyes ii) Check temperature- prevent hypo/hyperthermia iii) Check weight daily iv) Frequent breast feeding/increasing allowance for fluid v) Reassess frequently

TROUBLE SHOOTING i) ii) iii) iv) INEFFECTIVE PHOTOTHERAPY i) ii) iii) iv) SIDE EFFECTS AND DANGERS i) ii) iii)

Check fuse Check plug Check Cord Change tube if flickering or ends are blackened Baby covered Some tubes not working Flickering light Tube ends have black circles Hyperthermia/Hypothermia Increased insensible water loss Tailor fluid intake to meet demands

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MAINTENANCE i) ii) iv)

Change tubes - if ends black or - every three minutes Check flux (if possible ) Annual Maintenance contract

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3. SUCTION MACHINE OBJECTIVE

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Upon completion of this section the participant should 1. Know the parts of a suction machine 2. Know how to use a suction machine and 3. Know its sterilization

PARTS

: o Suction Catheter o Suction tubing o Suction bottles

TYPE

:

o De Lee’s suction trap o Foot operated o Electric ( if available ) WORKING : i) Connect to mains ii) Switch on the unit and occlude distal end to check the pressure. Ensure it does not exceed 100 mm of Hg iii) Use disposable suction catheters iv) Connect to suction tubing v) Perform suction gently vi) Switch off the suction machine vii) CLEANING & DISINFECTION i) Wash suction bottle with soap & water ii) Change bottle solution every day DOs & DONTs

:

i) ii) iii) iv)

Suction gently Do not do vigorous & deep suction Use only disposable suction catheters Check adequacy of suction pressure

i) ii) iii) iv)

Check fuse Check cord Check earthing Check for leakages in the bottle/tubing

TROUBLESHOOTING

SIDE EFFECTS & DANGERS i) ii) iii) iv) MAINTENANCE i) ii) iii)

Local trauma Bradycardia Apnea Infection Check for adequacy of suction pressure Change tubing if leaky or broken Annual maintenance Contract

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4. BAG & MASK OBJECTIVE

PARTS

: Upon completion of this section the participant should 1. 2. 3.

know the parts of a bag & types of masks be able to demonstrate the use of a bag know how to clean a bag & mask

i) ii) iii) iv) v) vi)

Body of the bag Oxygen inlet Air inlet Safety valve/pressure release valve. Patient outlet Valve assembly

:

WORKING

:

i) ii) iii) iv) v) vi) vii)

Assemble bag Check bag Connect to oxygen source Attach the reservoir Fix appropriate size mask Apply mask on manikin Ensure adequate seal Perform PPV-Check for chest rise

INDICATION

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i) ii) iii)

Apnea or gasping respiration HR<100/min Central cyanosis despite free flow oxygen

CONTRA INDICATION: i) ii) iii) CLEANING & DISINFECTION i) ii) iii)

Congenital diaphragmatic hernia Meconium stained liquor

DOs & DONTs

Check bag prior to use Choose appropriate size mask Use enough pressure to obtain easy chest rise Do not perform overzealous PPV Check for adequacy of ventilation ƒ Chest rise, Increase in HR, Improvement in color ƒ Appearance of spontaneous respiratory effort Check and maintain adequate seal

:

i) iv) v) vi) vii)

viii)

Wash with soap and water daily Soak in glutaraldehyde 2% for 6 hrs once a week Clean mask with spirit between patient use

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TROUBLE SHOOTING i) ii) iii)

Change bag Check for oxygen source Remedial actions for no chest rise

i) ii)

Clean and disinfect as per protocol Replace if damaged or leaky

MAINTENANCE

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5. WEIGHING MACHINE OBJECTIVE

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Upon completion of this section the participant should be 1. 2. 3.

Know how to calibrate the weighing machine Be able to demonstrate the use of the weighing machine Be able to classify newborns by weights as NBW/LBW/VLBW & ELBW

PARTS

:

i) ii) iii)

Pan or baby tray Weight scale dial Machine proper

WORKING

:

i) ii) iii) iv) v) vi) vii) viii) ix)

Wipe clean the weighing pan Check for and adjust zero error Calibrate using a known weight Place baby with sheet Note weight (a) Remove baby Weigh the sheet above (b) Subtract b from a (a-b) Record weight

CLEANING AND DISINFECTION i) Clean with soap and water ii) Wipe with spirit swab b/w patient use DOs & DONTs

:

i) iii) iv) v) vi) vii)

Always look for and adjust zero error Always calibrate using a known weight Weigh baby naked with a just a nappy Remove excessive clothing Do not stack up linen or other objects on the weighing pan when not in use Record weight only when needle is stationary & not oscillating.

TROUBLESHOOTING:

MAINTENANCE

i) ii) iii)

Place on a flat firm surface Calibrate before each use Record zero error if it can not be corrected and account for it

i) ii)

Calibration Annual maintenance contract

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6. PULSE OXIMETER OBJECTIVE:Upon completion of this section the participant should • Know the parts of Pulse Oximeter. • Know how to use a Pulse Oximeter. • Be able to demonstrate the working of the pulse oximeter • Know how to interpret the Pulse Oximeter readings. • Be able to take care of its daily maintenance and minor troubleshooting • Know how to clean it. PARTS:→ → → → → → → → → → →

Numeric display (LED). Graphic display (LED). SpO2 alarm limits, high / low setting button. Pulse rate alarm limits, high / low setting button. Display contrast adjusts slide. Power / Stand by button. Carrying handle Sensor Connector. Pulse Beep volume button. Alarm volume button. Alarm silence button.

WORKING: → Connect to Main. → Use the mode switches in the oximeter real panel to set the language, averaging mode, patient mode, patient’s pulsatile value display and EMI line frequency. → If you change the switch settings while the oximeter is on, the new settings do not take effect until you power OFF then ON again. CLEANING AND DISINFECTION: → To clean the display panel, use a cotton swab moistened with 70% isopropyl alcohol and gently wipe the panel. → To clean the outer surface of the oximeter, use a soft cloth dampened with a mild soap and water solution or one of the following solutions : ) 70% Isopropyl OR ethyl alcohol.

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) ) ) )

Quaternary ammonia 3 volume % hydrogen peroxide in water 100 : 1 bleach solution Cidex plus activator.

DO’S & DONT’S: ¾ Do not autoclave, pressure sterilize OR gas sterilize. ¾ Do not soak or immerse the monitor in liquid. ¾ When cleaning the display area do not use abrasive cleaning compounds OR other

materials that could damage the screen. ¾ Do not use petroleum based solutions, acetone solutions OR other harsh solvents to clean the oximeter. TROUBLE SHOOTING:-

) Check fuse. ) Check Plug. ) Check Battery ) Check for internal failure. ) Check for disconnected OR failed Speaker. ) Check for sensor failure. SIDE EFFECTS & DANGERS :/ / / /

Failure of operation. Explosion hazard in presence of any flammable anesthetis mixture. Electrical shock hazard. Patient conditions such as reddening, blistering, skin discolouration etc. Because of the sensor placement.

Maintenance

; Cleaning the Oximeter as necessary. ; Recharging the battery as necessary. ; Replacing the fuses in power module as necessary.

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PULSE OXIMETER

Oxygen saturation in percent

Display monitor

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Heart rate

Plethysmograph

Patient sensor

HOW DOES IT WORK A sensor device consisting of two light sources (red and infrared) and a photo detector is placed over a pulsating arteriolar bed (e.g. on the finger, toe, ear) opposite each other. Light moves through the tissue and is absorbed by the pulsatile arteriolar bed of the intervening tissue bed. The light passing through the tissue bed after absorption is measured by the photo detector and displayed as the plethysmograph as well as a numeric value in percent. This value is a ratio of the oxygenated to deoxygenated hemoglobin. WHAT IT MEASURES Blood is made up of plasma and cells (red and white blood cells, platelets,etc.). Oxygen is both dissolved in the plasma and bound to hemoglobin. Hemoglobin is within the red blood cells and oxygen bound to it absorbs infrared light whereas deoxygenated or reduced hemoglobin absorbs red light. The pulse oximetry reading reflects the amount of hemoglobin SATURATED with oxygen at the time of measurement.

WHAT IT DISPLAYS Most machines display a waveform (plethysmograph), a bar or a light sensor which indicates that the machine is picking up an adequate pulse. The machine is expected to read accurately over a 70- 100% saturation range. The basic model of pulse oximeter shows the pulse rate, SpO2 numeric value and the waveform.

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DRAWBACKS • Unreliable readings in hypothermia, hypotension, vasoconstriction and motion artifacts. • Abnormal hemoglobins are not accounted for like CO poisoning and methhemoglobinemia. • Does not work well in bright ambient light. PRECAUTIONS • Don’t apply the probe tightly • Rotate the site of probe applications as delicate neonatal skin tends to get compressed and there could be perfusion problem. • Clean the probe with only clean cotton swab with distilled water (ideally one probe is for one baby only).

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7. INFUSION PUMP (SYRINGE PUMP) OBJECTIVE :•

Upon completion of this section the participant should 1. Know the parts of a Syringe Pump. 2. Be able to demonstrate the working of a syringe pump. 3. Be able to set proper rate for fluid administration 4. Be able to settle minor trouble shooting and take care of the apparatus 5. Know the dangers associated with its use.

PARTS :→ Syringe barrel clamp → Pusher & Push guard. → Handle & Assembly bolt. → Main connection, fixing button. → Swing lock clamp. → ON / OFF. → Main warning. → Screen. → Silence Alarm. → Bolus OR Prime. → Value Selection. → Pre Alarm & Alarm Warning. → Stop – Infusion stop. → Menu WORKING : → Connect to Main. → Press on key to turn the pump on. → Install syringe loaded with desired amount of fluid with pressure line attached and primed. → Press OK to confirm syringe. → Select the flow rate. → Connect the Patient. → Start the infusion. → Check IV site regularly to avoid inadvertent extravasations. → To give a BOLUS, press the bolus key and continue pressing till the desired amount has been infused. → Press STOP to stop the infusion.

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CLEANING & DISINFECTION:Use a cloth soaked in DETERGENT – DISINFECTANT, previously diluted with water required to destroy micro organisms.

if

DO’S & DONT’S : ¾ Do not place in autoclave or immerse the device. ¾ Disconnect battery before opening device. ¾ Avoid short circuits and excessive temperatures. TROUBLE SHOOTING:-

) Check continuous display. ) Check indicator lights. ) Check alarm and safety features. SIDE EFFECTS & DANGERS :/ SHORT CIRCUITS & EXCESSIVE TEMPERATURES. MAINTENANCE :-

; Preventive maintenance is recommended every 3 years .This includes battery replacement. Accurate fluid infusion and drug administration is crucial for the optimum management of critically sick and small neonates. Continuous and controlled intravenous delivery of fluids and common medications, such as antibiotics, dopamine, phenobarbitone, aminophylline and others via infusion pump is the preferred mode of therapy in acute care. This is especially true for drugs with short half lives, so as to maintain a desirable constant serum concentration and in situations when constant infusion of glucose is needed. Small babies or those with compromised renal, cardiac or pulmonary function have limited fluid tolerance and hence it is essential to use infusion pumps so as to prevent inadvertent volume overload.

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CLINICAL SKILLS

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1. TEMPRATURE RECORDING & THERMAL CONTROL OBJECTIVE : i. ii. iii.

Upon completion of this session each participant Should be able to record axillary temperature in a newborn Should be able to clinically asses hypothermia, cold stress and normal temperature. Should be well versed with ways to achieve thermal control during domiciliary care, institutional care & transport.

RATIONALE : Temperature recording is a simple bedside tool to assess the baby’s temperature and ascertain the degree of hypothermia EQUIPMENT & OTHER REQUIREMENTS: i) ii) iii) iv) v) vi)

Low reading/Normal thermometer A manikin /newborn Cotton Swabs Cotton sheet A wrist watch Mother or other caregiver to demonstrate kangaroo care

i) ii) iii) iv) v)

Drying Wrapping & covering the baby Recording temperature Tactile assessment of temperature ( Cold stress assessment) Kangaroo care

SKILLS:

PROCEDURE : i)

Drying

ii)

Wrapping

iii)

Record temperature i) ii) iii)

Dry baby from head to toe, on the back, front, axillae & groin and discard wet linen. Wrap the baby using a sheet spread the sheet fold one corner on itselfplace baby’s head on the infolded corner so as to cover the head till the hairline on forehead. Cover over the right shoulder & tuck on left side. Fold from the foot end & tuck beneath the chin & finally cover over the left shoulder and tuck on the right side.

Place the baby supine or on the side Ensure dry arm pit Abduct arm at shoulder. Place the bulb of the thermo meter in the apex of the axilla

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iv) v) iv)

Hold arm in adduction at shoulder & flexion at the elbow for three minutes. Remove thermometer & read temperature

Tactile assessment i) ii) iii) iv) v) vi)

v)

Wash hands Rub them to dry Rub together & warm them Touch the baby’s soles & palms the dorsum of your hands Now touch the baby’s chest using the dorsum of your hands If both are warm-normothermic, if periphery is cold but chest is warm – cold stress, if both are cold – hypothermic baby. Kangaroo Care i) ii) iii) iv) v) vi)

Ask mother or caretaker to wear a loose shirt or blouse Unbutton top 2-3 button & slip baby with only the napkin on, into the shirt. Ensure skin to skin contact b/w baby & care taker Tie a belt or string at the belt level prevent the baby from slipping down Cover the mother baby duo with a woolen shawl or sheet Encourage frequent breast feeding.

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2. INFECTION PREVENTION

OBJECTIVE : Upon completion of this session each participant i) ii) iii)

RATIONALE:

Should be able to demonstrate steps of hand washing Should be able to clean and disinfect newborn care equipment and environment. Should be able to provide routine eyes & cord care and be able to advise mother regarding maternal & baby hygiene. Prevention of infection in newborns is easily achievable by simple measure like hand-washing and keeping baby’s environment clean. Prevention is much more rewarding as therapy for neonatal sepsis is not always successful.

EQUIPMENT & OTHER REQUIREMENTS: i) ii) iii) iv) v) vi) vii) viii) ix) x) xi) xii)

SKILLS

:

Soap Running water Hand washing chart Disposable delivery kit Cord tie Cord stump Spirit Sterile Cotton Sterile blade Manikin Disinfectant solution Newborn care equipments • Bag & mask • Laryngoscope • Thermometer • Oxygen hood • Skin probe • Cots/mattresses • Sheet • Suction machine i) ii) iii)

Hand Washing Equipment disinfection Eye & cord care

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PROCEDURE : I. Hand washing (Ref to Annexure III pg 60 ) • wet hands • apply soap • Rub hands, first palms & fingers • Then back of hands • Followed by rubbing of thumbs • Finally rub finger tips in the palms & lastly • The wrists • Keep elbows dependent & wash in the same order II.

Equipment disinfection i) Resuscitation bag & mask Face mask( Disinfect daily and sterilize weekly) • Clean with detergent daily and after each use • Immerse in 2% gluteraldehyde • Rinse with clean water and dry with sterile linen (washed and sun dried) • Resuscitation bag ( Disinfect daily and sterilize weekly) • Dismantle parts • Clean with Detergent • Immerse in 2 % glutaraldehyde • Rinse with clean water and dry with sterilize linen • Reassemble the parts ii) Laryngoscope • Wipe blade with 70% isopropyl alcohol after use. iii) Thermometer • • •

Ideal to have separate for each baby Wipe with alcohol after use Store in bottle containing dry cotton

iv) Oxygen hood • Clean every day or after use each use with detergent v) Costs and mattresses Clean everyday with 3% phenol or 5% Lysol Replace mattresses whenever surface covering is broken vi) Suction apparatus • Suction bottle should contain 3% phenol or 5% Lysol • Suction bottle should be cleaned with detergent and changed daily

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• • •

Change tube connected to bottle daily. Flush with water and dry Soak for disinfection in 2 % gluteraldehyde Ideally suction for catheter should be for single use

vii)Feeding utensils • •

Cup, spoon and paladai should be boiled for at least for 15 min before use. Feeding tubes should be preferably disposable.

• •

Keep cord dry Clean cord base and keep dry Do not apply anything

III. Care of Cord & eyes Cord

Eyes

-

Clean eyes from medial to lateral side separate sterile saline Soaked cotton swabs for each eye.

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3. BREAST FEEDING/ASSISTED FEEDING: OBJECTIVE : i) ii) iii) iv) v)

RATIONALE:

Upon completion of this session each participant Should be able to advise mother on manual expression of breast milk. Should be able to provide gavage feeds to the baby Should be able to provide katori spoon feeding to the baby Should be able to advise mother regarding therapy for retracted nipples. Should be able to allay all fears & anxiety of a lactating mother regarding adequacy & superiority of breast milk. Advantages of breast milk are many fold and this mode of feeding id the ideal for all neonates.

EQUIPMENT & OTHER REQUIREMENTS: i) ii) iii) iv) v) vi) vii) viii)

Lactating mother Katori/cup Spoon/paladay 6 fr & 8 fr feeding tubes 10 ml & 5 ml syringes Adhesive tape Manikin Blade

SKILLS: i) ii) iii) iv)

Manual Expression of breast milk Gavage feeding Katori spoon feeding Treatment for retracted nipples

PROCEDURE: i)

Manual expression of Breast Milk • Ask mother to sit comfortably, lean forward and support the breast over a bowl using both hands • Position the thumb and the forefinger at the margin of areola on both sides & press the breast tissue into the ribcage • Maintaining the backward pressure start bringing the thumb & the forefinger of each hand towards the nipple • Repeat the same several times till not further milk can be expressed out.

ii)

Gavage feeding • Take 6 fr or 8 fr catheter depending on the gestation and weight • Measure length from angle of mouth to tragus to xiphisternum

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• • • • •

iii) i) ii) iii) iv) v) vi)

iv)

Insert the tube from mouth till the desired length has been introduced Check position using a syringe & a stethoscope to auscultate the gush of air Tape the tube & close outer end after removing the syringe To instill feed-Take a 10 ml syringe barrel without the plunger and insert nozzle into the open end of the feeding tube. Check abdominal girth at next feeding session & proceed to feed if no increase in girth. If the girth increases by 2 cm., do a prefeed gastric aspirate and analyse the amount and content to decide about continuing/discontinuing feeds.

Katori spoon feeding Take baby in the lap hold the baby semi upright with head well supported. Stimulate the angle of the mouth and rest the spoon with 1-2 ml milk at the angle of the mouth. Pour milk slowly into open mouth & watch for swallowing. Gently stroke behind the ear or on the sole. Continue feeding in this manner till the desired amount has been fed. Burp the baby Place in right lateral position with head supported a little higher than the rest of the body. Treatment of Retracted nipples

Antenatal i)

Teach mother to roll out nipple between thumb and forefinger several times a day.

Postnatal i) ii) iii) iv)

Take a 10 ml syringe, cut the nozzle end transversely using a new blade Take care that the syringe barrel’s cut margin is not ragged. Insert plunger into the barrel from the cut nozzle end Place the barrel’s open end on the areola including the nipple in the barrel & pull back the plunger as far as possible. Repeat this several times & follow putting the baby to the breast to encourage suckling.

4. ASSESSING CFT & VENOUS ACCESS: OBJECTIVE :

Upon completion of this session each participant i) ii)

Should be able to assess perfusion by using CFT method Should be able to catheterize the umbilical vein

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iii)

RATIONALE

Should be able to demonstrate peripheral venous access on an improvised model.

i) CFT-CFT is simple sign to assess perfusion (BP of the baby) of a baby. A CFT of >3 seconds denotes poor peripheral perfusion. This can also be prolonged in hypothermia due to peripheral vaso constriction. If the baby is hypothermic, CFT should be reassessed after temperature improvement. ii) Umbilical. Venous access – It is a quick IV access for infusing volume expanders & drugs during resuscitation. iii) IV access: To provide parental fluids & medications

EQUIPMENT & OTHER REQUIREMENTS: i) ii) iii) iv) v) vi) vii) viii) ix) x) xi) xii) xiii) xiv) xv) SKILLS

Stop watch/wrist watch Umbilical cord 1 ft Blade Forceps Normal saline 2ml/5ml syringe 5fr. Feeding tube or umbilical venous cannula. Straw, Splint , Tongue depressor Polythene sheet Spirit Iodine Gloves Soap & Water Sticking tape Splint

: i) ii) iii)

CFT assessment Umbilical venous cannulation on a cord stump. Peripheral IV access on an improvised model.

i)

CFT assessment • Wash and dry hands • Press the forehead or sternum using index finger /thumb for 5 sec, release and look at the blanched area for return of color. Note the time taken for return of color. Note the time taken for return of the color. Normal CFT is upto 3 sec • CFT>3 secs indicates poor perfusion, however in presence of hypothermia interpretation may be fallacious.

PROCEDURE :

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ii)

Umbilical Venous Cannulation This activity shall be carried out on the umbilical cord provided to the participants. Each participant shall perform this activity and acquire the skill. • • •

Wash hands & dry. Wear gloves Connect syringe to the catheter, flush the catheter with saline & keep ready Take a small piece ( about 10 cm long ) of fresh umbilical cord in a kidney tray Hold or mount cord Cut the umbilical cord transversely clean with a sterile blade. Identify 2 arteries & 1 vein – the umbilical vein is a thin walled patulous large opening in contrast to the arteries which are thick walled and much smaller in caliber. ( In the normal position the umbilical vein is at 11-12 ‘O’ lock position) Insert the saline filled catheter gently into the vein( Black flow of blood can be appreciated in a live baby by pulling at the plunger ) In actual situation the length of the catheter to be inserted is usually 1-2 cm below the skin till there is a free flow of blood. Inject the drug or volume Pinch the catheter & remove. Press the cord to prevent bleeding.

• • • •

• • • • • iii)

IV Access: The training for gaining an intravenous access shall be done on a model which is provided. Each participant shall carry out this skill on this given model. -

Select the vein (dorsum of hand/foot ) Wash hands and dry Wear gloves Prepare skin- betadine, spirit, let dry between applications Hold the limb proximally to make the vein prominent Pierce skin distal to the intended ‘site of puncture Insert needle into the vein (feeling of give way ) Ensure free flow; thread the needle further up into the teeth Secure the scalp vein needle by adhesive tape Secure splint Inject fluid/medications Check distal limb for adequacy of circulation

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CASE STUDIES

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CHECKLIST FOR NEWBORN CARE Cases discussed will be managed on the principle of TABCFMFMCF as detailed here T.A.B.C. F.M. F.M. C.F. Hypothermia Cold Stress

- Provide heat - Skin to skin contact, Warmer,

Normal Hyperthermia

- Cover adequately - Uncover

1. Temperature - Assess

Maintained 2. Airway Compromised

-

Open and maintain airway • Position • Suction

3. Breathing None or gasping Normal Respiratory distress Normal 4.

-

PPV with 100% oxygen No intervention Provide oxygen

-

No intervention

Circulation-CFT >3 seconds

-

-

* Normal saline bolus * Check temperature * Check heart rate

5.

Fluids

6.

Medications

Pneumonia- IV antibiotics -Ampicillin, Gentamycin Apnea IV Aminophyllin Meningitis- IV antibiotics Bleeding Inj Vitamin K 1mg IM Convulsions – Inj Phenobarbitone, Inj Phenytoin ( Refer to annex. no. 3 Pg. 36 )

7.

Feeds

Weight<1200 gm-Gavage feeds Weight 1200-1800 gms- Katori Spoon feeding Weight > 1800 gms- Breast feeding Amount – ( Refer to annex no. 2 Pg. 35 )

-

If CFT >3 sec IV RL/NS 10ml/kg If stressed baby IV 10% Dextrose 2ml/kg If circulation not compromised-Normal requirement ( Refer to annex no. 1 Pg. 34 )

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8. Monitoring i) Temperature Touch method Temperature record 2 hrly ii) Respiration Apneic Gasping Tachypneic – RR Retractions +/Grunts +/iii) Color Pink Pink with peripheral cyanosis Pale Cyanosis iv) Heart rate Normal Tachycardia Bradycardia v) CFT Normal >3 secs vi) SpO2 90-93 <90 >93 vi) *Danger signsBleeding - Inj Vit K 1 mg IM stat Apnea - Tactile stimulation & PPV Grunt - Oxygen Severe retractions - Oxygen abdominal distension - NPO * Refer immediately without delay 9. Communication a) For referral i) ii) iii) iv) v) vi) vii) b)

Inform parents/relatives about baby’s referral Inform need for referral Communicate place of referral Communicate with the higher centre if possible Send a written note about details of birth & care Send a health worker with the family if possible Mother to accompany as far as possible

For hospitalized neonate in SCNU i) Inform neonate’s status to family at least twice daily ii) Report on temperature, colour, perfusion and general activity iii) Report on progress in terms of resolution of RD, requirement of O2, IVF, IV Antibiotics, Feeding.

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c)

10. Follow up

For home care i) ii) iii) iv) v) i) ii) iii) iv) v)

Exclusive breast feeding Maintain temperature- teach tactile assessment Prevent infection- Cord & eye care Danger signs- Early care seeking Maternal nutrition, rest supplements & spacing Follow up 2 weekly initially for 2-3 visit Check weight, mode of feeding, enquire problems during each visit Follow up every month thereafter Immunization advice Complimentary feeding advise

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Case Study – 1 A 5 days old term baby with a birth weight of 3200 gm is brought to the casualty in the hospital with yellow palms and soles. The child has a temperature of 360C. The respiratory rate is 52/min. The CFT is > 3 secs. How would you triage this neonate? At the Hospital: S. Bil – 24 mg/dl MBG – B Negative BBG - B Negative How would you manage this child?

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Case Study – 2 A 7 day old newborn is brought in with complaints of fast breathing and inability to feed at the breast. The weight today is 2250 gm as against 2450 at birth. The temperature is 360C respiratory rate is 80/min with moderate retractions and grunt but no cyanosis. What is your diagnosis? How will you manage the baby?

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Case Study – 3 A, 35 weeks gestation baby weighing 2550 gms at birth was feeding well at the breast and on day 5 developed discharge from the umbilicus followed the refusal of feeds and lethargy the next day. He vomited twice, had a feeble cry and on way to the hospital had a convulsion. At the hospitalWeight - 2400 gm Temperature - 370C Clinical exam - Drowsy RR-56/mim, no retractions, no grunt CFT-5 secs. Abdominal distention and poor bowel sound with a normal fontanel. What is your diagnosis? How will you manage this baby?

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ANNEXURES

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Annexure 1.

Guidelines for fluid requirement in neonates Guidelines for fluid requirements * First day 60-80ml/kg/day * Daily increment 15ml/kg till 150 ml/Kg

Fluid requirement (ml/kg) Birth weight

Day of life > 1500 g

1 2 3 4 5 6 7 onwards

< 1500 g

60 75 90 105 120 135 150

80 95 110 125 140 150 150

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Annexure 2.

Guide lines for feeding of LBW neonates Feeding schedule *

*

Begin at 60-80 ml/kg/day increase by 15 ml/kg every day maximum of 180-200 ml/kg/day First feed at 2hrs of age then every 2 hrly

Guidelines for the methods of providing fluids and feeding _______________________________________________ Age Categories of neonates _______________________________________________ Birth weight ( gm ) < 1200 1200-1800 >1800 Gestation ( wks ) <30 30-34 >34 Condition______________________________________________________________ Initial

Intravenous fluids Gavage Try gavage feeds, If not sick

After 1-3 days

Gavage

Katori-spoon

Breastfeed

Later (1-3 week)

Katori-spoon

Breastfeed

Breastfeed

After some more time

Breastfeed

Breastfeed

Breastfeed

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Breast feeding If unsatisfactory, katori-spoon feeds

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Annexure 3.

DRUG CHART DRUG

Ampicillin Gentamycin

Amikacin Cefotaxime Chaloramphenicol Aminophylline Vitamin K

DOSE

ROUTE

< 7 days 50 mg/kgdose, q 12 hr > 7 days 50 mg/kg/dose, q 8 hr

IV

Sepsis/ pneumonia 2.5 mg/kg/dose, q 12 hr or 5 mg/kg/dose, q 24 hr Meningitis: < 7 days 2.5mg/kg/dose , q 12 hr > 7 days 2.5 mg/kg/dose, q 8 hr

IV

< 7 Days 7.5 ml/kg/dose, q 12 hr

IV

IV

IV

< 7 days 50 mg/kg/dose, q 12 hr > 7 days 50 mg/kg/dose, q 8 hr 12 mg/kg/dose q 12 hr

IV

5 mg/kg loading, then 2 mg/kg/dose q 8-12 hr 1 mg

IV IM

Phenobarbitone

20 mg/kg loading over 10-15 min then 3-4 mg/kg q 24 hr

Phenytoin

15-20 mg/kg loading over 10-15 min then 5 mg/kg q 24hr

Dopamine/Dobutamine

5-20 micro g/kg/min

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Loading IV Then IV, IM or Oral IV IV continuous

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Annexure 4. NEWBORN HISTORY AND EXAMINATION Baby of _____________________________ (Mother’ name )

Age ______ Sex___

Date of birth_______________ Time______ Maternal history Age _____

Para ________

Gravida ________

Previous Obstetric History

Present pregnancy LMP ___/___/_____ Expected date of delivery ___/____/______ Present gestation in weeks ________ Antenatal History Antenatal check ups : Yes/No If yes where _______________ Number _____________ BP ___/____ mmHg

Urine examination: Albumin + / - tetanus toxoid: ____ doses

Blood group ___________ Any other investigation _____________________________ Family history of mother: _____________________________________________________ Labor

Presentation: Vertex / Breech / Transverse

APH

Placenta previa

PROM

Spontaneous/induced

Duration: _______ (hours)

Amniotic fluid : Clear/meconium stained Drugs in Delivery mode :

labour Normal Vaginal/Forceps/Vacuum/Caesaran

Indication, if not normal vaginal ______________________________________________ Anesthesia: General / Spinal

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Baby Resuscitation required Medications Apgar scores

None/ Initial steps / Free Flow oxygen / PPV / CC /

1 min. _______ 5 min. ________ 10 min. __________

Presenting Complaints: 1.

___________________________

2.

___________________________

3.

___________________________

General Examination I.

General condition : Alertness/Sensorium – Normal / Drowsy / Comatosed Activity & Cry: Good / weak / Poor

II.

Vital signs :

1 Temperature ______oC (axillary)

Peripheries warm/cool

2 Respiration rate _____ (per minute)

Retraction

3 Heart rate _____ (per minute)

All pulses palpable Yes/ No.

4. BP/Perfusion

Capillary refill time (CFT) ___ seconds

III.

:

Grunt

Apnea

Anthropometry

Weight _____ (gms) Gestation:

Head circumference ______ (cms)

Length _________(cms)

Term/Preterm/Post term

IV.

Position on intrauterine growth chart:

AGA/SGA/LGA

V.

Congenital malformations (Head to toe examination) :

________________________________________________________________________ ________________________________________________________________________

VI.

Other features Cyanosis

Icterus

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Seizures

Fontanel: Level / Bulging

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Systemic Examination

Diagnosis Single or multiple/Gestation in wk/Wt in gms/ AGAor SGA/ Sex/ add problems Management Plan 1. 2. 3. 4. 5. 6.

____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

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CHECKLIST FOR NEWBORN CARE

Annexure 5.

Cases discussed will be managed on the principle of TABCFMFMCF as detailed here T.A.B.C. F.M. F.M. C.F. Hypothermia Cold Stress

- Provide heat - Skin to skin contact, Warmer,

Normal Hyperthermia

- Cover adequately - Uncover

1. Temperature - Assess

Maintained 2. Airway Compromised -

3. Breathing None or gasping Normal Respiratory distress

4.

Open and maintain airway • Position • Suction -

PPV with 100% oxygen No intervention Provide oxygen

Normal

-

No intervention

>3 seconds

-

* Normal saline bolus * Check temperature * Check heart rate

Circulation-CFT

5.

Fluids

-

6.

Medications

Pneumonia- IV antibiotics -Ampicillin, Gentamycin Apnea IV Aminophyllin Meningitis- IV antibiotics Bleeding Inj Vitamin K 1mg IM Convulsions – Inj Phenobarbitone, Inj Phenytoin ( Refer to annex. no. 3 Pg. 36 )

7.

Feeds

Weight<1200 gm-Gavage feeds Weight 1200-1800 gms- Katori Spoon feeding Weight > 1800 gms- Breast feeding Amount – ( Refer to annex no. 2 Pg. 35 )

-

If CFT >3 sec IV RL/NS 10ml/kg If stressed baby IV 10% Dextrose 2ml/kg If circulation not compromised-Normal requirement ( Refer to annex no. 1 Pg. 34 )

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8. Monitoring i) Temperature Touch method Temperature record 2 hrly ii) Respiration Apneic Gasping Tachypneic – RR Retractions +/Grunts +/iii) Color Pink Pink with peripheral cyanosis Pale Cyanosis iv) Heart rate Normal Tachycardia Bradycardia v) CFT Normal >3 secs vi) SpO2 90-93 <90 >93 vi) *Danger signsBleeding - Inj Vit K 1 mg IM stat Apnea - Tactile stimulation & PPV Grunt - Oxygen Severe retractions - Oxygen abdominal distension - NPO * Refer immediately without delay 9. Communication a) For referral i) ii) iii) iv) v) vi) vii) b)

Inform parents/relatives about baby’s referral Inform need for referral Communicate place of referral Communicate with the higher centre if possible Send a written note about details of birth & care Send a health worker with the family if possible Mother to accompany as far as possible

For hospitalized neonate in SCNU i) Inform neonate’s status to family at least twice daily ii) Report on temperature, colour, perfusion and general activity iii) Report on progress in terms of resolution of RD, requirement of O2, IVF, IV Antibiotics, Feeding.

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c)

10. Follow up

For home care i) ii) iii) iv) v) i) ii) iii) iv) v)

Exclusive breast feeding Maintain temperature- teach tactile assessment Prevent infection- Cord & eye care Danger signs- Early care seeking Maternal nutrition, rest supplements & spacing Follow up 2 weekly initially for 2-3 visit Check weight, mode of feeding, enquire problems during each visit Follow up every month thereafter Immunization advice Complimentary feeding advise

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Annexure 6. Schedule of immunization ________________________________________________________________________

Age

Vaccine

0-7 days BCG, OPV, HBV 6 weeks OPV, DPT, HBV 10 weeks OPV, DPT, HBV 14 weeks OPV, DPT, HBV 9 months Measles 15 months MMR 18 months OPV, DPT, School entry (4-5 years) OPV, DPT 10 years dT (every 5 years) ________________________________________________________________________

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Annexure 7.

CHART FOR PHOTOTHERAPY as per AAP Guidelines 2004

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Annexure 8.

CHART FOR EXCHANGE TRANSFUSION as per AAP Guidelines 2004

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Annexure 9.

KRAMMER’s Rule for assessment of cutaneous levels of Jaundice

6 9 12 15 18-20

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Annexure 10.

Flow diagram for management of neonate with seizures Neonate with seizures: Identify and characterize the seizure Secure airway and optimize breathing, circulation and temperature Start O2 if seizures are continues Secure IV access and take samples for baseline investigations including sugar, hematocrit, sepsis screen and calcium, magnesium, electrolytes where feasible If blood sugar < 40 mg/dl, give 2 – 4 ml/kg 10% dextrose If seizures continue IV phenobartone 20 mg/kg over 20 min If no control Rpt phenobarbitone 10 mg/kg till a total of 40 mg/kg If seizures continue Give phenytoin 20 mg/kg over 20 min

After control of seizures initiate maintenance doses

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Annexure 11.

Volume of packed RBC transfusion calculation Weight in Kg x Blood Volume per Kg x ( Desired PCV – Observed PCV) Hematocrit of blood to be given Average blood volume of newborn is 80 ml/kg. The hematocrit of Packed RBCs is 70 and whole blood is around 50 Example: In infant weighing 1.5 kg is on ventilator, needs 40% oxygen and has a haematocrit of 30. The volume of packed cells required to be transfused will be 1.5 x 80 x (40 – 30) 70

=

17 ml

The maximum transfusion should be 10-15 ml/kg. Volumes larger than 15 ml/kg are to be divided. The transfusion should be given over as period of 3-4 hrs. Exchange transfusion with packed RBC is preferred when there is severe anemia and large volume is required to correct anemia. This would help to prevent CHF due to circulatory overload. Stockberg Formula to calculate the volume of Packed cell needed for correction of anemia by Exchange Transfusion. Weight in Kg x Blood volume (ml/kg) x (Desired PCV – Observed PCV) Hematocrit of the blood to be given – HCTW HCTW = ( initial PCV + Desired PCV) /2

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Annexure 12.

How to give Dopamine 1 ml of commercially available contains 40 mg of dopamine. In a baby weighing 2.5 kg if we want to start dopamine at a rate of 10ug/kg/min: = 10 x 2.5 = 25 ug/min = 25 x 60 = 1500 ug / hour = 1500 x 24 = 36000 ug / day = 36 mg of dopamine in 24 hours It means if we add 0.9 ml of dopamine in 24 ml of fluid and give @ rate of 1 ml/ hr with syringe pump or 1 microdrops per min (which is virtually impossible) with the micro drip set, we will give dopamine @ 10 ug/kg/min Increment If we want to increase dopamine to15 ug/kg/min then give the same fluid @ 1.5 ml/ hr The above method is to give a separate infusion of Dopamine, however it could also be added to 24 hours fluid as explained below:

e.g. 2.5 kg neonate in shock with a fluid requirement of 100 ml/kg/day, has received 2 fluid boluses of 10 ml/kg of normal saline, without any improvement. Plan is Total Fluid needed for this baby in 24 hours = 100 x 2.5 = 250 ml /day Fluid to be given every 8 hours = 85 ml. Let us learn how much dopamine to be added in 8 hours fluid i.e. 85 ml to be given at a rate of 10 ug/kg/min Amount of dopamine required in one minute = 10 x 2.5 = 25 ug Amount of dopamine required in one hour = 25 x 60 = 1500 ug Amount of dopamine required in 8 hours = 1500 x 8 = 12000 ug = 12.0 mg 1 ml of available dopamine preparation = 40 mg of dopamine

To make 12 mg of dopamine we need 0.3 ml, add this volume to 85 ml of fluid and give over 8 hours at a rate of 10 ml/hour or at a rate of 10 micro drops /min with a burette set, which will deliver dopamine at a rate of 10 ug/kg/min

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Annexure 13.

Partial exchange transfusion • •

Peripheral vein or peripheral (radial) artery for bloodletting and peripheral vein for pushing in. Volume to be = Blood volume X (observed – desired hematocrit) Exchange Observed hematocrit Desired hematocrit = 55% Blood volume is estimated to be 80 – 90 ml/kg in term babies and 90 – 100 ml/kg in preterm babies. As a rough guide, the total volume of blood exchanged is 15-20 ml/kg. Example: An full term IUGR baby with a weight of 1.5 kg with an observed hematocrit of 75. To do a partial exchange transfusion the volume needed is: Blood Volume = 80 x 1.5 = 120 ml Observed Hematocrit = 75 Desired Hematocrit = 55 Volume to be exchanged = 120 x (75 – 55) = 32 ml 75

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14. Sample Referral Note Date __________

Time _________

Address _____________________________________________________________ ______________________________________________________________ Name _____________ Mother’s Name____________ Father’s Name __________ DOB ______________ TOB ___________ Sex __

Mother’s Blood Gp:

Birth Details Mode of Delivery _____________

Place of Delivery ________________________

Time of 1st Cry ____________ Apgar 1 min ___ 5 min ___ 10 min ___ Resuscitation details Initial steps / Free flow oxygen / Bag & Mask Ventilation / Chest compressions/ Medications Duration of: O2 ______, Bag & Mask Vent. _______, Chest compression ________ Birth weight _______ grams Clinical course Feeding well Yes / No, Breast feeds Yes / No,

Spoon Feeds Yes / No

Type of feeds EBM / Formula / Any other milk Passage of

Urine Yes / No

Diluted milk Yes / No

Stool Yes / No

Reason for transfer LBW / Respiratory distress/ Not feeding well/ Convulsions/ Jaundice/ Malformation/ Any other Examination Findings Jaundice Yes / No

Any congenital malformations _________________________

Soles Warm/Cold,

Trunk Warm/Cold

Temperature ______ oC

Heart Rate ____ / min

Resp Rate ____ / min Chest Retractions Yes / No

Central Cyanosis Yes / No

CFT < 3 sec / > 3 sec

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Receiving oxygen Yes / No With Nasal canula / Face mask / Oxyhood SaO2 ____%

Dextrostix ______ mg%

Time of Last Feed ________am/pm Investigations with date ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Treatment Given ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Place to which being referred ____________________________________________________ Mode of transport ____________________ Accompanying person ______________________ Name and Phone number of person at Referral Hospital _______________________________ ____________________________________________________________________________

Signatures, Name, Date and Time

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ANNEXURE 15. IU Growth Chart

Preterm LFD

Term LFD

L F D

Term AFD

A F D

Preterm AFD

Term SFD

S F D

Preterm SFD

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ANNEXURE 16. Expanded New Ballard Score for Gestation assessment

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