11+ concepts you NEED to UNDERSTAND before taking care of Neonates!!!

So make sure that if you have a preemie baby you're giving them that shot of coffee that they need. Hello and welcome to Tala Talks NICU where we break down neonatal medicine and make it super easy for you to understand and hopefully retain forever. Today since it's close to the beginning of the school year whether you're a resident or intern or whether you're a nursing graduate we figured that we would make a list of 11 things very random number that you should probably know when you go into the NICU. We talked about calling them facts but they're never facts in medicine things that we think are facts today may be completely disproved in a few years. Before I continue can I please ask you to like this video as well as if you do comment to us then please tell us where you're actually watching from. So let's start 11 things that you have to know if you are walking into the NICU whether it's your first day or whether it's your thousandth day. The first point is about drug errors. The most common drug errors so when a baby gets way too much drug or less drug than they should get made in the NICU are normally by a factor of 10. So they're either getting 10 times too much or 10 times too little and there are two main reasons for this. The first one is is that a lot of the drugs that we give in the NICU the kind of average dosing is in a factor of 10. So for example we would give 0.1 milligram per kilo of morphine or 0.1 milligram per kilo of midazolam. We'd give one microgram per kilo of fentanyl one milligram per kilo of lasix. We'd give 10 milligrams per kilo of caffeine. So you can see that these all have slightly different units and maybe slightly different units and they're all kind of between 0.1 and 10. So it's pretty easy to make a mistake when all the numbers are kind of like in a scale like that. The second reason and this is probably an even bigger reason is that we give the medication in doses per kilo but the variation in the amount of weights that you have in the NICU is absolutely massive. So you can have a 450 gram baby or you can have a five kilo baby. So it's very difficult to get used to all these different kind of doses for such a wide variation in weights. So for example a five kilo baby that you're putting on maximum lipids so say it's a surgical baby and you're running three grams per kilo of lipids you could run that at 3.1 mls an hour. If you made a mistake and tried to run lipids at 3.1 mls an hour for a 500 gram baby that would be an outrageous amount of lipids. So just be very aware of that just be very aware of the different weights and the different dosages and the different units that we commonly use in the NICU and always go through the correct checks and balances that you should be going through. Okay number two the treatment of hypoglycemia in the NICU. So if you have a baby in the NICU with a low sugar and there's lots of conversation about what that low sugar is maybe it's less than 30 maybe it's less than 45 somewhere around there and the baby is not feeding then you want to give a sugar bolus and the dosage of an IV dextrose bolus is two milliliters per kilo of D10 and you basically give it as a push. So for example if you have a 750 gram baby with a sugar of 18 just after delivery then 0.750 times 2 you would give 1.5 mls of D10 via IV. Just a couple of things that I want to say here the first thing that you need to consider is if the sugar is mildly low so say you have that 750 gram baby and the first sugar is 32 but you haven't actually started fluids yet then you don't necessarily have to give a bolus you can just go ahead and start the maintenance fluids that you're running and then make sure that you follow up on the sugar afterwards. The second thing that you need to remember is that giving the IV bolus of the D10 is really just a band-aid so you really need to make sure that you're giving that bolus and you're doing something else after that so whether you're going up on the rate or you're going up on the dextrose concentration so basically going up on the GIR you need to make sure that you are making some changes otherwise what will happen is you'll give the IV dextrose bolus the insulin will spike in the baby and then the next sugar might be even lower than that first one so you give the bolus but you should also be changing something else as well. The third thing is about sepsis obviously I was going to talk about this so whenever a baby does anything unusual so baby's too hot too cold much more lethargic so sleepier than normal the tone is down baby suddenly starts feeding a lot less baby starts having more A's and B's or starts needing a lot more oxygen the first thing that you need to consider is sepsis like I've said many times before babies especially premature babies are effectively immunocompromised so it doesn't take a lot for them to get infected and for that infection to spread all over their bodies so if you are at all concerned by sepsis then you should be doing something about it it doesn't even have to be starting antibiotics or getting blood work just make sure that you're following that baby more carefully maybe you're doing serial physical exams or you're measuring the urine output more closely just always be aware that your baby may be developing sepsis. The fourth point is about caffeine. Caffeine is amazing it's probably the most well-studied drug in the NICU and it should definitely be given to all babies born at less than 30 weeks you give it immediately as soon as they hit the NICU basically and if a baby is needing significant respiratory support and they're kind of less than 32 or 33 weeks then you should be considering caffeine in them as well. Caffeine decreases the events the number of times that the baby has apnea of prematurity the severity as well as the frequency it also has been shown to decrease the incidence of BPD or chronic lung disease also in these follow-up studies a lot of data suggests that caffeine if anything may just independently help neurodevelopmental outcomes so make sure that if you have a preemie baby you're giving them that shot of coffee that they need. Okay number five is delivery room knowledge there are two important numbers that you need to know in the delivery room lots of other things obviously that you have to know but just remember these two numbers the numbers are 60 and 100 so if a baby is delivered and the baby's heart rate stays below 100 despite resuscitating despite drying and stimulating the baby the baby's heart rate is less than 100 then you need to start positive pressure ventilation or actually breathing for the baby if the heart rate goes below 60 despite the fact that you're giving good positive pressure ventilation preferably with an endotracheal tube then you need to start chest compressions so less than 100 you start PPV less than 60 you start chest compressions if you're doing chest compressions then you should probably be intubating that kid and also start opening up the lines and everything else with a plan of giving epi. Number six is our love-hate relationship with oxygen so as I'm sure a lot of you already know this that it is really bad for babies to be exposed to really high oxygen it causes oxygen toxicity and it increases the obviously we also don't want the oxygen to be too low and there have been endless research articles trying to investigate exactly what the ideal saturation is for preemie babies right now we assume that the ideal saturation is somewhere in the early 90s so kind of 88 to 94 percent is where you want the saturations for growing infants obviously if the baby is on 21 percent FiO2 or room air and the baby's satting 100 percent then that's great but if you're actually delivering oxygen to the baby then you just want the sats in kind of the low 90s one important exception to this is if you are giving chest compressions or the baby is coding do not worry about BPD or ROP you are trying to save that baby's life and crank that FiO2 all the way up 100 percent the rest of the time be extremely aware of what the baby's saturations are make sure that the alarm is alarming when the saturations are in the 99 or 100 percent point number seven is kind of understanding how much respiratory support we expect a premature baby to need so say you get called to the delivery room and you find out the gestational age of a baby what are you expected to have to provide that baby if the baby is a 22 or 23 weaker most likely nearly all of the time you're going to have to intubate that baby if the baby is 24 weeks or above really up to about 30 weeks then there's a really good chance that the baby is going to be fine just on CPAP and normally we're giving CPAP from 24 to 30 weeks if the baby obviously has a really high FiO2 need or is not breathing or you get to the unit and the CO2 is through the roof obviously you're going to have to intubate that baby but from 24 weeks onwards our hope our goal is to try to get these babies out of the delivery room at least on CPAP after 30 weeks you're really kind of evaluating in the delivery room exactly what these babies need there's a good chance that they still may need CPAP up to kind of 32 weeks but even a 31 meeker might just need a little bit of nasal cannula or really might not need anything in the delivery room so to reiterate 22 23 weeks you're probably going to intubate them 24 to 30 weeks at least try with CPAP may need to intubate them anyway and above 30 weeks try to evaluate exactly how much they need number eight is keep the baby warm I should have probably said this earlier because it really is one of the most important things that we do in the delivery room as well as in the NICU and that is to try to maintain the baby's temperature all babies especially premature babies are at really high risk of becoming hypothermic or getting a temperature of less than 36.5 degrees celsius and there are loads of reasons why the babies are born wet they have really thin skin they had don't have a lot of fat on them they're not very good at actually creating heat in their bodies so it really doesn't take a lot for their body temperatures to just plummet and if babies do get cold they are way more likely to have worse outcomes so more likely to have IVH as well as more likely to die just from having hypothermia shortly after birth so it's really important that we keep these babies warm and a lot of the equipment that we have in the NICU is actually dedicated to this nine is about growth this is another thing that we're completely obsessed with in the NICU and that is how well the babies are growing we weigh them every single day and we check the head circumference and every week and then we track those parameters along the growth curves we want the babies to be tracking outside the uterus exactly like they would be tracking inside the uterus and we know that the better they grow the better that their heads grow the better their neurodevelopmental outcomes so growth is super important for us if babies aren't growing well enough then we will add calories or fortifies to the milk that we're giving them or increase the GIR and the TPN to try to give them exactly the protein and the calories and everything to try to get them back on their right track we know that one of the most important aspects that contributes to good growth is babies getting good amounts of protein and that includes starting the protein really early so if a baby is born at less than 32 weeks then get some protein in the initial fluids that you're giving and we have bags of starter TPN or vanilla TPN every unit calls them something else which are ready-made bags with just sugar and protein in it so that you can start those pre-babies on good amounts of nutrition from very soon after birth there's also a lot of conversation about what sort of gestational age and weight we should be placing central lines or more specifically an umbilical venous catheter generally I will place one in a baby that's born at less than 1500 grams it's a pretty arbitrary number but that will ensure that we will have good venous access for a week it will also ensure that we can maximize the nutrition in these little babies obviously sometimes we're putting uvcs and babies bigger than that but if a baby is less than 1500 grams I'm pretty much always putting in a uvc okay number 10 also super important is breast milk breast milk is probably one of the most effective medications that we give premature babies it is one of the only things that has been shown to decrease the incidence of necrotizing enterocolitis or neck in premature babies many units have donor breast milk available but even though this hasn't really been proven we kind of assume that mother's breast milk is probably slightly better than the donor breast milk which is better than the formula so encourage mothers to pump encourage them to start pumping early soon after delivery talk about it in your prenatal consults when the babies are in the unit and the mothers are not able to directly breastfeed their babies then it's just a really really stressful time for mothers it's really really difficult for them to actually produce the breast milk that their babies need so acknowledge how difficult this is for them and talk about it and continue to encourage them however much breast milk that they bring in even if it's one ml every day then just give them the positive reinforcement they're obviously trying their best and they're just in a very very difficult situation and any breast milk is great and point number 11 kind of following on from the whole breast milk mother thing is the importance of involving the parents and the entire family in the NICU stay and in the management of the baby and this is really important for two different reasons the first is that this is an incredibly difficult time in a parent's life it is most of the time very unexpected a lot of people don't even know that a NICU exists or that so many babies end up in the NICU it's also very stressful the mother just gave birth all the hormones everything that she may be going through she may have just had surgery there are financial stresses there are stresses within relationships so it's just a very very difficult time for all families with babies in the NICU so involving them in management decisions and making them part of the team gives them some control over what is going on in their lives and obviously that is extremely important for both the parents as well as the baby the second reason why it's so important to keep families involved is that families especially if they're at the bedside a lot get to know these babies so well they're their own children so whoever may be rounding however much we love the babies however much the primary nurses or the practitioners go and examine the babies it's still not the same as the parents sitting there and very often it's the parents who are like i've noticed that my son is just a lot sleepier today or that he's puking up a lot or the vomit is going across the room so listen to what the parents are saying because not only do mothers have absolutely fantastic intuition but they know their baseline and their babies better than just about everybody else so listen to those parents okay that's it i hope that that helped let me know if there's anything else that you think i should have added to that or we should have added to that and in the meantime please remember to like this video and if you're interested in NICU stuff to subscribe to this channel thank you so much