pat scheans, dnp, nnp-bc clinical support for …...neonatal topics du jour: new news about newborns...

Neonatal topics du jour:

New news about newborns

2017

Pat Scheans, DNP, NNP-BC

Clinical Support for Neonatal Care

[email protected]

Objectives

1. Promote “physiologic” cord clamping

2. Incorporate the new 7th edition NRP changes into practice

3. Integrate use of glucose gel for hypoglycemia

4. Reduce antibiotic use for risk of early onset sepsis

5/2/2017 RANDALL CHILDREN'S HOSPITAL 3

Disclosure of relevant financial relationships in the past 12 months:

▪ I, Dr. Scheans have the following to disclose: consultant for Clinical Innovations

▪ No products related to this lecture

Physiologic Cord Clamping

Why? When? Where? How?

What’s the big deal?

▪ Immature cells capable of differentiating into many cell types

▪ Essential role in development and maturity of nervous, respiratory, cardiovascular, hematologic, immunologic, and endocrine systems long before birth

▪ May impart long-term benefits against age-related diseases

▪ Impact on brain injury?

5/2/2017 LEGACY HEALTH 5https://usercontent2.hubstatic.com/3711983_f260.jpg

We’re

special!

What is it?

▪ Immediate = w/in 1 minute (usually 15-30 seconds)

▪ Delayed/timed/physiologic/optimum = 30-60 seconds

5/2/2017 LEGACY HEALTH 6

Why delayed/timed/physiologic/optimum

cord clamping?

▪ Neonatal total blood volume 85 mL/kg

▪ Doesn’t take much volume loss to get into trouble

> Immediate cord clamping: 30-50% of blood left in placenta

▪ proportional to gestational age

▪ 80-100 mL transferred w/in 3 minutes

▪ 90 % within first few breaths

▪ Stem cell-rich blood


What are the benefits?

▪ Increased iron stores -> decreased iron deficiency anemia -> improved developmental outcomes

> Especially important in low resource countries

> Fine-motor/social domains @ 4 years -- especially in boys▪ Low risk/high income country- Sweden [Andersson, 2015]

▪ Reduced incidence & severity of intracranial hemorrhage (IVH) (39-74%)

▪ Increased blood volume -> reduced need for blood transfusion (2-3 x less)

▪ Decreased rates of sepsis & necrotizing enterocolitis (NEC)


Hemodynamic stability


▪ Fetal shunts-> cardiac output drop with immediate

clamping due to decreased pre-load

▪ Decreased cardiac workload -> increase in superior vena

cava flow esp. if ventilation established (13% to 43%)

▪ Increased blood volume and blood flow -> improved tissue perfusion

“Apparently healthy spontaneously breathing neonates are

more likely to die or be admitted if CC is performed before or

immediately after onset of SR.”

> Increased risk not related to duration of time between CC and SR but

rather to the intervention CC that preceded SR

> Risk decreased by 20% for every 10 seconds up to 2-minute delay in

CC after onset of SR

[Ersdal et al, 2014]

5/2/2017 LEGACY HEALTH 10http://evolutionaryparenting.com/wp-content/uploads/2013/07/CORD-CLAMPING.jpg

Supporting normal physiology

▪ Fetal cardiac output = 10% to lungs

▪ Foramen ovale shunts blood to left atrium -> ascending

aorta -> heart & brain

▪ Immediate clamping -> high pulmonary vascular

resistance + decreased preload -> drop in cardiac

output

▪ Clamping while breathing -> dilatation of pulmonary

vascular bed -> venous return from lungs to left atrium

& maintains left ventricular pressure -> cardiac output

-> systemic blood pressure


When to immediately clamp?

▪ Placenta or umbilical cord not intact

> Abruption

> Cord avulsion

▪ Resuscitation needed +/-

> Being studied

> Cord intact during NRP makes perfect physiologic sense


How to?

5/2/2017 LEGACY HEALTH 13http://i2.cdn.cnn.com/cnnnext/dam/assets/150529152253-umbilical-cord-baby-exlarge-169.jpg

Headed your way


NRP trolley

http://www.inditherm.co.uk/wp-content/uploads/2013/08/14573-015_Attach_ControlFront.jpg

Take home points


▪ Placental transfusion = 1st step in resuscitation

▪ Pre-brief cord clamping plan

▪ Minimally 30-60 seconds

> especially for pre-terms

> while establishing respirations

▪ Must have intact placenta and cord

▪ Watch for resuscitation trolley

▪ Ted talk: TICC TOCC Dr. Alan Greenehttps://www.youtube.com/watch?v=Cw53X98EvLQ

http://www.chicagonow.com/chicagos-worldly-tastes/files/2013/05/chinese-take-out.jpg

NRP 7th Edition

Why? How?

Pre-Brief with OB team

Cord clamping plan

1.Timed unless placental or cord issues

2.Dry and stimulate

3.Call out in 15 second intervals


NEW

Pre-Brief newborn team

3 ROLES:

1. Leader: airway -> MR SOPA

2. Apgar timer, CR monitor leads, pulse ox, compressions,

oxygen

1. 30% if < 30 weeks

2. 100% if compressions needed

3. IV access -> low emergency umbilical vein line,

intraosseous

1. Epinephrine: 1:10,000 0.1- 0.3 mL/kg every 3- 5 minutes

2. Volume: normal saline or O negative blood 10 mL/kg


All together now….HALLELUJAH!


BUT…


NEW


NEW

Listen for heart rate and air entry -> communicate w/in 15

seconds:

• Chest may be moving but heart rate not improving

• Heart rate may be improving but chest is not moving

Give 30 seconds of EFFECTIVE VENTILATION


Think LMA!

Waaaaaaaay easier!

NEW

Or

LMA

Emphasis on two thumb method

▪ Better cardiac output

▪ Move to head of bed for cord access


▪ Most effective compression:ventilation ratio is still 3:1

“1 and 2 and 3 and breathe”

Heart rate monitoring

▪ Use of 3-lead monitor with

compressions

▪ Auscultation over feeling

cord



Emergency low UV line- clean technique• Cheater dose -> 0.5 mL average-sized baby (0.1 if < 1kg)

Endotracheal dosing ineffective• 0.5-1 mL/kg only while obtaining IV access

• Give IV dose immediately upon IV access


10 mL/kg over 5-10 minutes

Always consider oxygen carrying capacity

Consider neuroprotective cooling

▪ Prevent hyperthermia

▪ Passive cooling after consulting NICU

> Improves HIE outcomes

> Turn down warmer and follow temperature closely

> Entrance criteria (RCH NICU)

▪ 35+ weeks plus one of the following:

▪ Umbilical or baby by one hour of age

▪ pH < 7 or base deficit > 16 (within 1 hour of birth) or

▪ pH 7.01-7.15 and base deficit 10-15.9, plus one of the following:

– Apgar < 5 at 10 minutes or

– Assisted ventilation (not CPAP) x 10 minutes post delivery


http://www.medpagetoday.com

http://www.abclawcenters.com

https://www.ucl.ac.uk

NO changes foreseen- the evidence is in…

▪ Later? Nope >> Initiate by 6 hours of age

▪ Longer? Nope >> 72 hours

▪ Colder? Nope >> 33.5° C

▪ Preemies? Nope >> 35 weeks and up

▪ Reduction in mortality & major disability at 6-7 years of age

▪ Outcome at 18 months of age is a good predictor of childhood outcome [Shankaran, 2014]


Take home points


▪ Ventilation, ventilation, ventilation

▪ Ventilation, even with meconium staining> Suction if needed- blood, mucus, meconium, etc

▪ 15 second check on PPV

▪ MR. SOPA -> LMA if can’t ventilate, can’t intubate

▪ 1 and 2 and breathe even with advanced airway

▪ CR monitor with compressions

▪ Hypovolemia = think oxygen carrying capacity


40% Glucose Gel for Hypoglycemia

Why? When? How?

Remember this…?


Why? New evidence to consider…

▪ Asymptomatic hypoglycemia retrospective outcome study

(Kaiser, 2015)

▪ Sugar Babies Trial outcomes (Harris et al, 2013, 2016)

▪ Higher blood sugar levels endorsed by Pediatric

Endocrine Society based on physiology (Stanley, 2015)> Plasma glucose levels are lowest early on the first day of life ~ 55-65 mg/dL

> Increase over next 2-3 days to reach range of normal for older infants and

children


Kaiser et al., 2015

▪ Paired 1395 babies born in 1998 with their 2008 achievement test

scores (at 10 years old)

▪ 6-19 % had transient hypoglycemia (<35, <40, <45 mg/dL)

▪ Early transient newborn hypoglycemia was associated with lower achievement test scores at age 10 years

▪ 50% as likely to perform at grade level on tests of math and literacy

▪ Normal glucose levels were about 20 percent more proficient than

those with transiently low glucose levels


“Sugar Babies” trial (Harris, 2013)

▪ Randomized, double-blind, placebo-controlled trial at a

tertiary center between Dec 1, 2008 - Nov 31, 2010

• 514 enrolled babies

• 242 (47%) became hypoglycemic

• 35- 42 weeks gestation

• < 48 hours old

• At risk of hypoglycemia

▪ Aim: assess whether treatment with 40% dextrose gel

was more effective than feeding alone for reversal of

neonatal hypoglycemia in at-risk babies

May 2, 2017 LEGACY HEALTH 38

How?

1) Dried baby’s mouth with gauze

2) Massaged 200 mg/kg (0.5 mL/kg) gel into buccal mucosa

> Equal to 2mL/kg mini bolus of D10W

3) Baby was encouraged to feed

4) Blood glucose measured 30 min after gel administration

> If feeding was poor, given expressed breastmilk or formula by

syringe, according to maternal wishes

▪ If remained hypoglycemic or hypoglycemia recurred

later, treatment was repeated

▪ Up to six doses of gel could be given over 48 hours


So?

▪ Treatment with dextrose gel is inexpensive and simple

to administer

▪ Dextrose gel should be considered for first-line

treatment to manage hypoglycemia in late preterm and

term babies in the first 48 hours after birth


But is it Baby Friendly? You decide…

▪ Spent less time separated from their parents

▪ At 2 weeks of age, formula feeding was less common in

babies receiving dextrose gel than in those receiving

placebo


▪ Advocate Lutheran General Hospital, Park Ridge IL

▪ Adopted the practice in 2014

▪ 0.2 grams/kg of 40% glucose gel up to three times

▪ Decreased admissions to NICU for hypoglycemia from 11%

to 3%

[Bennett, 2016]


▪ Dr. Kaiser is now at Baylor starting a clinical trial of 40%

glucose gel


Adult product

Off label

Flavored


FBC Screening and Management of Neonatal Glucose Homeostasis

Goals

Birth to 4 hours of age: blood glucose target = 40 mg/dL

4 to 24 hours of age: blood glucose target = 45 mg/dL

After 24 hours of age: blood glucose target = 50 mg/dL

Instructions

1. Feed all at-risk newborns within one hour of birth

o If unable to breastfeed due to maternal/neonatal condition: expressed mother’s milk, banked breast milk or formula 5-10 mL per feeding

o Gavage PRN 2. Screen all at-risk newborns 30 minutes after first feeding

3. Additional screenings are AC at a minimum of q 2-3 hours based on feeding frequency

4. Follow flow chart for interventions

o Preterm infants (<37 weeks) and SGA infants: screen birth to 24 hours of age (minimum) or until stable off of supplemental feedings

o Infant of Diabetic Mother (all types) and LGA infants: screen birth to 12 hours of age (minimum)


SCREEN ALL SYMPTOMATIC NEWBORNS IMMEDIATELY WITH GLUCOMETER

Apnea/cyanosis Decreased muscle tone/lethargy Diaphoresis/pallor Jitters/tremors

Poor feeding or sucking Seizures Temperature instability Weak or high pitched cry

SYMPTOMATIC

Any age: check glucose

< 40

o 40% dextrose gel 0.5 mL/kg

PO

o D10W 2mL/kg IV bolus

o Feed 5-10 mL

o Serum glucose to lab

o D10W 80 mL/kg/d IV

o Notify PCP

Screen post 1st feed, then AC x 2

Follow action flow chart PRN:

o Discordant twins (>10%)

o IV fluids (newborn)

o Terbutaline or beta

blocking agent within 48

hours of birth

o Perinatal stress: pH <7,

APGAR <6 @ 5 minutes

o Prolonged resp distress

o Post term > 42 weeks

o Suspected sepsis

o Temperature instability




SYMPTOMATIC

Any age: check glucose

< 40


PO


o Feed 5-10 mL



o Notify PCP







hours of birth





o Suspected sepsis






SYMPTOMATIC ASYMPTOMATIC

Any age: check glucose Birth to 4 hours of age 4 to 24 hours of age

< 40


PO


o Feed 5-10 mL



o Notify PCP

Feed by 1 hour of birth

Glucometer check 30 min PC

Feed q 2-3 hours

AC glucometer checks

1st Glucometer result -> Action

< 40

o 40%

dextrose gel

0.5 mL/kg PO

o Feed 5-10 mL

o Glucometer

check 1 hr

>40

Feed q 2-3 h

Glucometer

checks AC for

time period

as above

< 45

o 40%

dextrose gel

0.5 mL/kg PO

o Feed 5-10 mL

o Glucometer

check 1 hr

> 45

Feed q 2-3 h

Glucometer

checks AC

for time

period as

above







hours of birth





o Suspected sepsis


2nd Glucometer result -> Action

< 40


PO

o Feed 5-10 mL

o Glucometer check 1 hr

< 45


PO

o Feed 5-10 mL

o Glucometer check 1 hr

3rd Glucometer result -> Action

<40


PO


o Feed 5-10 mL



<45


PO


o Feed 5-10 mL



▪ Why don’t we just use 24% sucrose?

> Sucrose is a disaccharide and takes longer to metabolize than

dextrose

> Large volume would be needed

▪ What’s the difference between glucose and dextrose?

> Glucose is the same chemical as dextrose

> Monosaccharide breaks down more easily (faster)


Bolus IV vs Buccal

2 mL of D10W = 0.2 grams of dextrose

10 grams of dextrose 0.2 grams of dextrose

100 mL 2 mL

40% dextrose = 40 grams/100 mL

1 mL=0.4 gm 0.5 mL=0.2 gm


Sugar Babies follow-up study: Outcome at 2 Years after Dextrose

Gel Treatment for Neonatal Hypoglycemia: Follow-Up of a Randomized Trial

184 babies: randomized to dextrose (90) or placebo gel (94)

“Our primary aim was to determine whether treatment of

infants with hypoglycemia with dextrose compared with

placebo gel altered the rate of neurosensory impairment or

processing difficulties at 2 years’ corrected age.”


[Harris, D. et al., 2016]

Conclusion

“This study shows that treatment with

dextrose gel is not associated with

additional risks or benefits at 2 years of

age. Clinicians and families can be

reassured that the advantages of treatment

with dextrose gel soon after birth are not

counterbalanced by increased risk of poor

neurodevelopmental outcome at 2 years’

corrected age.”


IV Rx, NICU, mom-baby dyad disruption…

▪ 25% reduced to 14% (Harris)

▪ 11% reduced to 3% (Bennett)

▪ Legacy anecdotal reduction after 1 year


Take home points


▪ Screen at-risk infants

▪ Treat symptomatic newborns ASAP

▪ 40% dextrose gel is safe (albeit messy)


Neonatal Early Onset Sepsis

What? Where? When? Why? How?

WHY?

5/2/2017 54

▪ How many of you have treated a

newborn with antibiotics?

▪ How many of you have cared for a

newborn with a true positive blood

culture?

LEGACY HEALTH

Show of hands…

Why?

Newborn Early-Onset Sepsis is…

▪ Very infrequent in term infants since GBS screening and

prophylaxis began

> GBS sepsis rate dropped from 1.8 to 0.25 cases per 1,000 births1, 2

> Overall incidence of early-onset sepsis: 0.5-1.2 cases per 1,000 births3

Yet…

▪ Empiric antibiotic treatment remains VERY frequent

> 6-10% of ALL infants > 34 weeks receive antibiotics in first few days of

life4

5/2/2017 55

[1. Schuchat A, et al.1996 2. Weston EJ, et al. 2011 3. Puopolo KM, et al. 2011 4. Escobar GJ, et al. 2014]

LEGACY HEALTH

Why?

▪ 554 newborns (4.6% of all births) exposed to

chorioamnionitis at Thomas Jefferson University

> 100% treated with antibiotics

> 24% treated with prolonged antibiotics (>7days)

• 20% treated solely based on lab abnormalities

> 0.7% had positive blood culture


[Kiser C, et al. 2014]

When?

Risk factors for early-onset sepsis

> Preterm (most important)

> Rupture of membranes >18 hours

> Maternal GBS positive

> Maternal fever

> Maternal chorioamnionitis

5/2/2017 57LEGACY HEALTH

What else?

Antibiotic exposure hazards

> Increased cost

> Increased length of stay

> NICU exposes to multidrug-resistant bacteria

> Possible allergic reaction

> Possible oto- and/or nephrotoxicity

> IV pain/infiltrates

> Negative effect on gut flora long term

> Negative effect on bonding and breastfeeding

> Parental anxiety, long term effects on parenting attitudes and

behaviors


Why?


“Elementary, my dear Watson…”

Use of risk factors is deductive reasoning

Enter the Newborn Sepsis Risk Calculator

▪ Two key articles in Pediatrics 3,4

> 608,014 babies >34 weeks

▪ 4 hospitals in CA and MA between 1993-2007

> 350 culture confirmed bacterial infection at <72 hours

▪ Risk factors analyzed to create predictive model for early onset

sepsis

> Multivariate tool uses objective data to more precisely determine risk of

early-onset sepsis

5/2/2017 Randall Children's Hospital 60

[3. Puopolo et al. 2011, 4. Escobar et al. 2014]

What?


▪ Using maternal and neonatal data, defined risk

stratification into 3 categories:

>Treat empirically

>Observe and evaluate

>Continued observation

What?

Sepsis Risk Calculator Website

www.newbornsepsiscalculator.org


http://www.newbornsepsiscalculator.org/

Risk Calculator- Newborn Evaluation Added

5/2/2017 64

Clinical Exam Description

Clinical Illness

1. Persistent need for NCPAP / HFNC / mechanical

ventilation (outside of the delivery room)

2. Hemodynamic instability requiring vasoactive drugs

3. Neonatal encephalopathy /Perinatal depression

• Seizure

• Apgar Score @ 5 minutes < 5

4. Need for supplemental O2 > 2 hours to maintain oxygen

saturations > 90% (outside of the delivery room)

Equivocal

1. Persistent physiologic abnormality > 4 hrs

• Tachycardia (HR > 160)

• Tachypnea (RR > 60)

• Temperature instability (> 100.4F or < 97.5F)

• Respiratory distress (grunting, flaring, or retracting)

not requiring supplemental O2

2. Two or more physiologic abnormalities lasting for > 2 hrs

• Tachycardia (HR > 160)

• Tachypnea (RR > 60)

• Temperature instability (> 100.4F or < 97.5F)

• Respiratory distress (grunting, flaring, or retracting)

not requiring supplemental O2

Note: abnormality can be intermittent

Well Appearing No persistent physiologic abnormalities

Why?

▪ Sepsis risk calculator could decrease treatment

>10% to 4%

>80,000 to 240,000 fewer infants treated in US each year


Legacy Pilot of Sepsis Risk Calculator▪ Implemented January 2015 at LSC, LEH, LGS in hospitalist patients


Year Data LEMC LSC LGS Total2013 Sum of

Newborns2172 2548 1023 5743

Sum of Abx

w/in 3 Days272 236 44 552

% Treated 12.5% 9.3% 4.3% 9.6%2014 Sum of

Newborns2273 3408 1109 6790

Sum of Abxw/in 3 Days

283 228 41 551

% Treated 12.5% 6.7% 3.7% 8.1%2015 Sum of

Newborns2238 3330 1115 6683

Sum of Abx

w/in 3 Days193 85 17 321

% Treated 8.6% 2.6% 1.5% 4.8%2016 thru

April

Sum of

Newborns704 1137 379 2220

Sum of Abx

w/in 3 Days55 38 4 97

% Treated 7.8% 3.3% 1.1% 4.4%

Why?

▪ LEMC: decrease by 40%

▪

▪ LSC: decrease by 70%

▪ Overall: decrease by 55%


“Elementary- check the sepsis risk calculator.”


Take home points

Thank you!

References


ACOG Committee Opinion # 684. http://www.acog.org/-/media/Committee-

Opinions/Committee-on-Obstetric-Practice/co684.pdf?dmc=1&ts=20170413T1653526947

American Academy of Pediatrics & American Heart Association. (2015). Neonatal

Resuscitation Program (7th ed). AAP & ACOG: Elk Grove Ill.

Andersson, O., Lindquist, B., Lindgren, M., Stjernqvist, K., Domellöf, M., Hellström-Westas, L.

(2015). Effect of delayed cord clamping on neurodevelopment at 4 years of age: A

randomized clinical trial. JAMA Pediatr. 69(7):631-638. doi:10.1001/jamapediatrics.2015.0358

Bennett, C. (2016). Implementing a protocol using glucose gel to treat neonatal

hypoglycemia.

Nursing for Women's Health 20 (1): 64-74. doi:10.1016/j.nwh.2015.11.001

Chapman, J., Marfurt, S., & Reid, J. (2016). Effectiveness of delayed cord clamping in

reducing post delivery complications in preterm infants: A systematic review. The Journal of

Perinatal & Neonatal Nursing, 30(4), 372-378. doi:10.1097/JPN.0000000000000215

Chiruvolu, A., et al. (2015). Effect of delayed cord clamping on very preterm infants. American

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Ersdal, H. L., Linde, J., Mduma, E., Auestad, B., & Perlman, J. (2014). Neonatal

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peds-2014. doi: 10.1542/peds.2014-0467. available at:

http://pediatrics.aappublications.org/content/pediatrics/early/2014/07/09/peds.2014-

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doi:10.1016/j.jpeds.2015.10.066

Higgins, R. D., Saade, G., Polin, R. A., Grobman, W. A., Buhimschi, I. A., Watterberg,

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pat scheans, dnp, nnp-bc clinical support for …...neonatal topics du jour: new news about newborns...

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