Doctor covers: 25 VERY USEFUL NICU Tips

Hello, I'm Dr. Tala. Welcome to Tala Talks NICU, where we break down medical concepts and make them really easy to understand. This is kind of part two of our random 50 tips, so we already covered 25. Go watch the previous video, and now we're gonna go over another 25. Again, thank you to Anne Shields, one of our viewers who suggested this and offered some of the tips herself. Tip 26 is about noise levels. We are, in the unit, not good at staying quiet. There's loads of people in there. There's other babies. There's always stuff going on. We're chatting, and we're kind of enjoying our workdays and chatting with families, and it's generally consistently too loud. Remember that the baby is padded in utero and covered with fluid, so the noise that the baby experiences in utero is much, much lower than after the baby is born. The AAP recommends that the noise level in the unit should be less than 45 decibels, and occasionally, for less than a second at a time, if you're opening the incubator or something, going up to 65 to 70 decibels. All studies have shown consistently that having a consistently high noise can affect the growth and the development and just increase vital sign instability, so it doesn't take a lot to get those decibels really far up. Knocking on the incubator is way above 45 decibels, even a loud clang or a new admission or something, so the more we're all aware of this, the better the babies will do. 27, and this is about light levels, which is kind of, if you think about it, very similar to the noise level. Fetuses, obviously, are in complete darkness in utero, so when they're born early, they are not ready to handle the level of lights that we have, so it is very important that a premature baby is protected from very bright light. Ideally, babies in incubators, especially less than 30 weeks, should be not exposed to lights above 20 lux or two-foot candles, so two-foot candles is the best unit ever. One-foot candle is the amount of brightness created by one candle a foot away, so really not a lot of light. Less than 30 weeks, babies aren't capable of dilating and constricting their pupils to try to accommodate exactly how much light they want. As the babies get older, then we can allow them to be exposed to slightly more light. Once they reach 34 weeks, then we really want to start introducing them to the light of the day and the darkness at night so that they can start getting into their circadian rhythms. 28 is about parechovirus, and this is a virus that can cause a very severe sepsis in especially infants under three months of age, so they can go into end organ damage as well as it can go to their brain and cause encephalitis and can cause seizures. What you need to know, though, is if you tap these babies, their CSF can look like it's pretty normal, so there isn't necessarily a huge WBC count increase in their CSF, and if you're suspecting parechovirus, then you need to send the actual lab for this virus. 29, and this is about bilirubin. As you all know, in the last few years, we've kind of really changed our management of hyperbilirubin a lot. We've actually become a lot less conservative. So previously, in America at least, we always used to get blood types on babies. Now we're really only checking them if mother's a high risk or something else is going on. However, this point does not change. If the baby or the mother is Coombs positive, then we need to follow those bilirubins early. Those are at greatly increased risk of the bilirubin shooting upwards, because obviously if you're Coombs positive, you're a lot more likely to have active hemolysis going on. So if it's Coombs positive, make sure that you're following the bilirubin carefully. 30, if your baby has abdominal distension or is not stooling, then there's two things that you should be doing. The first one is make sure that you're actually doing a physical exam of the anal area. Make sure that there is an anal atresia and you're not missing anything anatomically. And two, and I would highly recommend this as well, make sure that you do some sort of rectal exam. So normally the way that I do it is I get a Q-tip and I cover it with KY jelly, and then I insert that into the anus just a little bit of the way up. If it is Hirschsprung's, very often when you take the Q-tip out, the stool will come, because you put it past the aganglionic area, the stool will come shooting out. I mean, I've had to change scrubs a couple of times during this exam. It is a very easy exam and it really can be very diagnostic. So again, if you are worried about abdominal distension and lack of stooling, then this really should be done before you're getting the KUBs and especially before you're getting the enemas. 31, if you suspect a metabolic disease, so when you don't think the kid is septic, the baby may have a lot of acid, maybe has a high ammonia, is acting really sick and you don't really know why, that's when you should be suspecting a metabolic disease. Then immediately stop the feed, stop the TPM, stop giving anything, no protein, nothing else, no fat. The only thing you should be giving the baby is glucose. So make the baby NPO and then immediately start the baby on a dextrose drip, probably above maintenance. So probably at least kind of 120, 130 mLs per kilo per day. 32, if you are worried about free air in the belly, so you're worried that there could have been a spontaneous intestinal perforation or neck that perforated, then you can't always tell it perfectly on an AP view. The best way to tell is on a left lateral decubitus. So that is when you're lying down on your left side, so your liver is on your right side. So what will happen is that the air will rise and will trap underneath the liver, so it will be a lot clearer rim, that kind of black rim of air under the kind of relatively more whitish grayish liver. So that can be a lot more obvious if there's free air when you do a left lateral decubitus. 33, do not give acid suppression drugs, so protein pump inhibitors or Zantac to premature infants. It can increase the risk of neck as well as mortality. So just don't do it. 34, this is about pulmonary hemorrhages. Pulmonary hemorrhages are terrifying in premature babies. They can bleed out and bleed to death very quickly. So whenever you're getting a bit of bright red blood suctioning from the endotracheal tube, tread very lightly. It is very concerning when babies do have even a bit of bright red blood. So things that you should be doing if that bright red blood is kind of increasing is you can increase the PEEP. And this kind of just hopefully by increasing the mean airway pressure, you're just kind of tamponading that bleeding. You could also try some really icy water or some epinephrine down the trachea, hoping that that's also going to constrict the area that is bleeding. Generally, you do not want to take the endotracheal tube out or even change it out because if you do, then that might just collapse the lungs altogether and the bleeding comes out. You will not be able to see the vocal cords again. So keep that endotracheal tube in and try to kind of increase the pressures. 35, what is the postmenstrual age? It is literally the age from the mother's last menstrual period. It's also basically the gestational age plus the chronological age. So for example, if a baby was born at 26 weeks, that's the gestational age, and the baby is now five weeks old, so that's the chronological age, then the postmenstrual age is 26 plus five equals 31 weeks. So we're now at 31 weeks postmenstrual age. And that's normally the age that we use in the unit. 36, what about the corrected age? So the corrected age is generally used after the babies are going home. So say a baby was born three months early, so born at kind of about 28 weeks. And when they're actually celebrating their one year birthday, really because they were born three months early, really they are now at a corrected age of nine months. And the reason why that's important is because then we don't have to have the same expectations of them with their milestones that we would if the babies were born at full term. Generally, we stopped correcting the ages of preemie babies when they reach about three years old. At that point, it should have all kind of grayed out and there should be catch up and stuff. But up until the age of three, then we're using corrected ages for premature babies. 37, in the first 24 hours of life, full-time babies only have to pass meconium once, and they have to have one wet diaper or literally urinate once. Obviously, every single day it increases until they kind of stabilize out. Preemie babies can take even longer to pass stool. It can be several days depending on how old they are. So also logically, if you do get a KUB of a baby within the first few hours of life, then you're not going to expect that gas to go all the way down to the rectum until they're probably about 24 hours of life. So just remember that when you're interpreting x-rays. 38, EB or epidermolysis bullosa is a really rare genetic skin disease that babies can be born with that it can have like a whole variability in severity. So it can be so bad that like the skin is just kind of all falling off, or it can be that the skin is just like a lot more fragile. So with trauma, it's a lot more likely to kind of slough off. These babies, after they're born, it almost looks like they've been burnt in utero. And when you look at the skin, the things that you're kind of thinking about, was it trauma against a bone? Or was there sort of amniotic bland or something that wrapped around that? It really almost looks like burns in utero. So if you see skin that especially kind of linearly looks like there's burns, then be thinking about EB. 39, and still talking about rashes, the other kind of really interesting rash is syphilis. So obviously, depending on how old the patient is, syphilis can present in loads of different rashes. What very commonly shows in term babies or even preemie babies, is that they can have really, really dry sloughing skin, almost like they were born like totally postterm. So like they're like a 42, 43 weaker and the skin is like sloughing off and just really, really dry. So you get like a sick 32 weaker with that really dry sloughing skin, think about syphilis. Okay, 40, when you're measuring the head circumference in babies, and this is important that we all do it the same way so that we can actually track it. So when you're measuring head circumference, go from the most prominent part of the forehead. So that's normally right above the eyebrows and then take it back so that it's over the occiput. So it's important for you to realize that in the first kind of couple of weeks of life, the head circumference doesn't mean a lot because normally there's a caput and there's like so much molding. But for our little preemie babies, we start following that very closely because as you all know, the head circumference correlates very well with growth and with development. 41, a little bit of genetics. Most of the time, if you're in an exam and you're not sure how the disease is inherited, then just guess autosomal recessive. Most diseases are autosomal recessive inheritance. There are a few X-linked diseases that you should know about and you should be aware about. Remember that X-linked diseases are much more likely to occur in males. In females, very often they can be masked by the other X chromosome that they have. So the X-linked diseases that you should know, a G6PD, which can cause deficiency, which can cause hyperbilirubinemia, much more common in males. You can have OTC or ornithine carbamole transferase. I think that's what it was sound for. Deficiency, which is a urea cycle defect. They love that question on exams. Haemophilia, as you all know, happens a lot more commonly in males. Wiskot-Aldrich, which is a immune deficiency and they can have like low platelets and stuff. Also X-linked deficiency. Also Darchein muscular dystrophy and red-green color blindness, as you all know is a lot more common in boys than it is in girls. Fragile X is also an X-linked disease. However, it's a dominant disease. So girls can actually suffer from fragile X because even having one abnormal X is enough to affect their IQs. 42, let's talk about evacuating pneumothoraces. So you basically have kind of two options that are generally accepted. The most important thing, especially if you're putting in a chest tube, especially if it's a girl really, is that you don't want to kind of affect future breast development. We want these babies to go home when nobody ever knew that they were in the NICU. So remember that the nipples generally are in the mid clavicular line, kind of at the level of the fourth rib. So you don't want to be going for a chest tube right there, boy or girl. So your two options are either to go in the fourth intercostal space, bisects with the anterior axillary line, so kind of down there, or you could go in the second intercostal space in the mid clavicular line. Whichever way you're gonna go, make sure that you position that kind of part upwards because as you know, the air will travel upwards and you're more likely to get the pneumothorax. 43, however, if you're trying to get rid of a pleural effusion, so there's an accumulation of fluid in the pleural cavity, then you can go lower down. So fifth or sixth space. And you want to go because fluid obviously is more likely to collect at the bottom than you want to go in the posterior axillary line. So further down as well as further back to collect the fluid as opposed to the air. Very logical. Okay, these next few tips all come from a post that we put on the NICU professional site on Facebook. So if you're not members there, I highly recommend that you go join because there's lots of really useful information. So thank you very much, Kaylee V, for sending us all of these. 44, and this one I use all the time, and she mentioned this, is the one, two, three rule for endotracheal tubes so that you can kind of remember the size of the endotracheal tube when you're in the delivery room or on the unit and trying to decide which one to use when you intubate a baby. So remember, one, two, three. When the baby is between one and two kilos, you use a size three ET tube. So generally, a baby is gonna be about one kilo at about 28 weeks. So between one and two kilos, use a size three ET tube. So the rest kind of falls into place. In the little ones, like less than 28 weeks, you're gonna use a 2.5 ET tube, and the ones above two kilos, you're going to use a 3.5 ET tube. Maybe in the huge term babies, you might go up to a four, but it's always the middle area that's the trickiest to remember. So one, two kilos, use a three ET tube. 45, again, I use this one. Although I'm sure in the next few years, all the phototherapy guidelines are going to change even for the tiny preemie babies as well. They've changed so much in the last few years for the older babies. But for now, generally, I use this a lot, that if you are wondering whether to light up a baby, then half the baby's weight. So for example, if the baby is 1.2 kilos, then assume that that's 12, then start phototherapy when the bilirubin is six. If the baby is 800 grams, then assume that's eight, and start phototherapy when the bilirubin is four. This is very conservative and starting phototherapy on the early side, but it's just kind of like a nice rule to have that you're not thinking, okay, you're also realizing that if the bilirubin is like 12 and the baby's weight is 1.2 kilos, then that's really high. 46, if the baby is having a lot of emesis or is just not tolerating their feeds, again, this is from Kaylee, try putting the baby on the right side, which kind of helps gastric emptying, or put the baby on its tummy, which also can kind of help the tolerance of feeds. Putting a baby on the tummy can also really help if the baby's having any sort of respiratory depression. So very often babies will have their positions that they like the most. So just think about that generally as you get to know your patient. 47, and this is just a great tip overall. If you are in a situation where you want to be able to tell how long something is going on for, so the baby is coding, the baby's having a horrible apnea bradydesac, the baby is having a seizure, and you really want to be able to go ahead and tell how long it is, then hit the Apgar timer. Very often, a lot of the isolettes in the unit will have the Apgar timers on them, and you'll have a better idea. Obviously, when you're in the middle of something, even if somebody is kind of writing out the code times, it can be very difficult to gauge exactly how long something is happening for. 48, and these are Kaylee's tips for blood draws. So if your unit allows it, and the baby is obviously feeding, then you can give some sweeties to kind of pre-medicate the baby before the blood draw. So then make sure that the baby's head is up a little bit, so you're using gravity to help that blood kind of drain down, and then swaddle all three extremities of the baby apart from the one that you're actually getting the blood from. 49, and this is another excellent nursing tip. At the beginning of every single one of your shifts, make sure that the suction tubing is working and that it's available, and the bag mask is working. You've got access to oxygen, especially if you can blended oxygen. There are so many times when unexpected things happen in the unit where we're all just scrambling around trying to get these things. So if you make sure at the beginning of every single shift that this is set up, then it could really solve huge problems in the future. And tip number 50 is from Courtney F. Hi, Courtney, we used to work together, and I never knew this equation. Thank you for sending it. If you want to double check the placement of your OG or your NG tube, then one of the things that you can use is this equation. And it is 2.5 times the weight plus either 12 for an OG or 13 for an NG tube. So for example, say you have a two kilo baby. So 2.5 times two is five. Add 12, so you have to insert it 17 if it's an OG, and 18 if it's an NG tube. I love it. It's just a good double check as you're using all your other parameters for seeing whether the OG and the NG are deep enough or not too far in. And 51, kind of like a bonus tip, because I say this all the time in the unit, we really, in the last kind of 20 years, tried to do as little as we can for the babies. So for example, when I was in residency and fellowship, these preemie babies, we were getting blood draws like twice a day and following the sodium and the potassium and everything else. But now we've realized that just doing so much stuff constantly to the baby, including blood draws, doesn't in any way help them. In fact, it could make them worse. So really, the less that we do for babies, the better, hoping that they're going to grow and develop as closely as they would be in utero. Remember as well, don't get lab tests just to confirm an academic guess. So yes, there's a murmur. If you're not gonna do anything about it anyway, then don't get an echo. Same thing with an X-ray. If it's not gonna change your management in any way, then just don't get that lab test. Don't get that imaging because it really is all just additional stress on the baby. And so those were our 50 tips. I really hope you learned something. If you think of any more, then please write to us either at our email or comment below and remember to tell us where you're from. We really appreciate having you here. In the meantime, please remember to like this video and to subscribe if you're interested in all things neonatal content. Again, thank you.