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<< The Nightmare Neonate: Life -Threatening Events In The First Month Of Life
Specific Interventions
Airway And Breathing
Critically ill newborns often require intubation either for airway protection or to decrease the work of breathing in profound shock. Premature babies may need to be intubated with a 2.5 mm endotracheal tube, while full-term babies can typically be intubated with a 3.0 endotracheal tube. The Broselow tape is more accurate than the typical age-based formula of (16+age in years)/4 in determining the size of theendotracheal tube.54
Deep suctioning of the nasopharynx can be extremely helpful in infants with bronchiolitis. Wheezing may respond to aerosols, and racemic epinephrine may be more effective than beta-agonists.77,78 The debate regarding steroids for bronchiolitis continues. While some patients may benefit from steroid use, it is not clear that steroids should be routinely used for management.79,80 Because of the risk of bronchiolitis-related apnea, most texts recommend hospital admission for infants less than 3 months of age, those who have been previously intubated, or those who have cardiac disease.81
In the cyanotic infant, methemoglobin levels of 25%- 30% will impair oxygen delivery and should be treated with 1-2 mg/kg IV of methylene blue.13
Fluids And Pressor Support
ED management of the newborn in shock includes volume repletion with normal saline in 20 cc/kg boluses to treat shock. If the etiology of shock is unclear, and congenital heart disease is suspected, then it may be prudent to start with 10 cc/kg boluses. If the child appears to be in septic shock, be aggressive in fluid administration. One study showed that children who receive greater than 40 mL/kg of normal saline in the first hour of care do better than those who receive less than 20 mL/kg.82 If the patient’s blood pressure and mental status do not improve with a total of 60-80 cc/kg of normal saline, then additional measures are indicated.
In the presence of hemorrhage, packed red blood cells should be given, starting with 5-10 cc/kg. For septic or cardiogenic shock, the initial drug of choice is dopamine, starting with 6-10 mcg/kg/min. Central venous access may be useful since tissue necrosis can result from peripheral pressor infiltration.9
If intravenous access cannot be obtained in a critically ill neonate, start an intraosseous line, preferably in the proximal tibia. Fluids and most resuscitation drugs can be given by this route. A pressure bag can ensure adequate flow rates if the child is profoundly volume-depleted.
Glucose Replacement
Hypoglycemia in the newborn is defined as a plasma glucose level of less than 30 mg/dL.83 However, symptomatic patients with blood sugars less than 60 mg/dL should be treated, because infants and newborns have low glycogen stores.84 To treat hypoglycemia in neonates, start with 2 cc/kg of D10 solution and repeat as needed.
Medications For Seizures
Benzodiazepines are the first line of treatment for neonatal seizures, followed by phenobarbital, fosphenytoin, or phenytoin.43 Lorazepam is preferred as it causes less respiratory depression than diazepam and provides a greater duration of anti-seizure activity.45 Phenytoin has a depressive effect on the newborn myocardium and has an unpredictable rate of metabolism due to immature hepatic function.45 Pyridoxine (50-100 mg IV) or lidocaine may be used if refractory seizures are present. (See Table 6.) If the seizure is a result of an electrolyte abnormality such as hyponatremia, hypocalcemia, or hypomagnesemia, rapidly replete these deficiencies. Hyponatremia can be corrected with either normal saline (0.9%) boluses or alternatively with 5-7 mL/kg IV of 3% saline (this can be administered as a bolus given over 10 minutes). If the patient has hypocalcemia (plasma calcium < 7.0 mg/dL), administer 100-300 mg/kg IV of 10% calcium gluconate. In cases of hypomagnesemia (serum magnesium < 1 mEq/L), 0.1-0.3 cc/kg of 50% magnesium sulfate should be given intravenously or intramuscularly. Consider the need for antibiotics or antiviral medication in infants with seizures.
Medications For Cardiac Disturbances
If ductal-dependent congenital heart disease is suspected based on central cyanosis in the first 2-3 weeks of life, treat the infant empirically. Begin an infusion of prostaglandin E1 (PGE1) at a rate of 0.005 mcg/kg/min and titrate upwards to a maximum of 0.1 mcg/kg/min. Prostaglandin is a potent vasodilator and will immediately begin to re-open the ductus. Improvement is usually seen within 15 minutes; however, the practitioner should be prepared to intubate since apnea is a side effect of PGE1. Other complications of prostaglandin use include fever, hypotension, and seizures. There are few pediatric studies on the management of congestive heart failure; therefore, most of the management regimens have been based on the adult literature.85,86
Furosemide (1 mg/kg) is still considered a good initial agent, but it may need to be combined with digoxin, morphine, nitrates, dobutamine, or dopamine based on the clinical circumstances. Beta-blockers such as carvedilol should be used with caution as they have a high incidence of hypotension and bradycardia.86 Angiotensin-converting enzyme inhibitors may have a role in pediatric congestive heart failure; however, data are limited,86 and it may be helpful to contact a pediatric cardiologist prior to initiating these agents.
Supraventricular tachycardia is the most common symptomatic dysrhythmia in infants and children. Treatment depends on whether or not the child is stable. If the newborn is in extremis, immediately cardiovert the child with 0.5-1.0 J/kg. In the stable patient, vagal maneuvers such as crushed ice in a plastic bag applied to the infant’s face can prove successful.87 If this fails, give adenosine 0.1 mg/kg followed by a normal saline flush of 5 cc. If unsuccessful, administer an increased dose of 0.2 mg/kg.9 Further interventions are best conducted after consultation with the pediatric cardiologist. Options may include digoxin (10 mcg/kg IV initial load, second dose in six hours, and third at 24 hours) and procainamide (10-15 mg/kg IV over 30-45 minutes). Verapamil should not be used in children under 1 year of age as cardiovascular collapse and death can occur.88
Antibiotics/Antivirals
Children at risk for sepsis benefit from early empiric antibiotics. Antibiotics should cover the more common pathogens in this age group. Empiric regimens may include a combination of ampicillin 100 mg/kg IV and a thirdgeneration cephalosporin such as cefotaxime 50 mg/kg IV. Another traditional combination is ampicillin 100 mg/kg IV and gentamycin 2.5 mg/kg IV. Both of these regimens are effective against Listeria, E. coli, and Group B Streptococcus. Some specialists add vancomycin 10 mg/kg IV to cover drug-resistant organisms, especially if the cerebrospinal fluid is visibly purulent.89
While a recent study of 120 neonates found no blood or cerebrospinal fluid cultures positive for Listeria,22 many authorities still believe that antibiotic coverage against Listeria remains indicated. If the cerebrospinal fluid results are consistent with meningitis, a third-generation cephalosporin with good central nervous system penetration, such as cefotaxime, is recommended, with some specialists expanding coverage with vancomycin depending on the local incidence of penicillin-resistant Pneumococcus.90 The American Academy of Pediatrics Committee on Infectious Diseases suggests that dexamethasone 0.15 mg/ kg IV be considered for children with pneumococcal meningitis. 91 Recent data in adults show that dexamethasone given shortly before or concurrent with antibiotics improves outcomes in bacterial meningitis.92
Begin acyclovir (20 mg/kg q8h IV) if there is a positive maternal history of herpes, a vesicular rash, focal neurologic findings, cerebrospinal fluid pleocytosis, or elevated cerebrospinal fluid protein without organisms on Gram’s stain.93
Metabolic Interventions
The most important ED intervention in the neonate with an inborn error of metabolism is to rehydrate with normal saline boluses. This is followed by a maintenance fluid of D10 0.45% normal saline at 1.5-2.0 times the normal rate to promote excretion of the toxic metabolites.38 Insert a Foley catheter and target a urine output of 1-2 cc/kg/h. Correct hypoglycemia and administer a continuous glucose infusion. Discuss the need for sodium benzoate (for urea cycle defects), sodium bicarbonate, or sodium phenylacetate administration with the pediatric endocrinologist. Dialysis may be necessary to decrease serum organic acids, and patients should be admitted to the neonatal or pediatric intensive care unit for further management.
If the child has evidence of congenital adrenal hyperplasia, resuscitate with boluses of normal saline if the child has evidence of shock or volume depletion. Consultation with a pediatric endocrinologist may be helpful in deciding on the maintenance fluids. Administer hydrocortisone 25 mg IV, then 25-50 mg/m2/d divided every 6-8 hours (approximately 25 mg every 6-8 hours in full-term newborns).18 (The body surface area is equal to the square root of the: [height in centimeters multiplied by the weight in kilograms] divided by 3600.) Hyperkalemia typically responds to fluid replacement alone; however, severe hyperkalemia, especially if dysrhythmias are present, should be treated with 10% calcium gluconate (100 mg/kg), sodium bicarbonate 1 mEq/kg, insulin 0.1 unit/kg with D10 3-10 cc/kg, and kayexalate.18 Monitor serum glucose closely as these patients are frequently hypoglycemic.
At times children with neonatal thyrotoxicosis will present in a hypermetabolic state. Management includes propanolol 2 mg/kg/d divided three times a day to decrease the tachycardia and hypermetabolic state. Production of thyroid hormone can be decreased with propylthiouracil 5-10 mg/kg/d or methimazole 0.5-0.7 mg/kg, followed one hour later by potassium iodide (Lugol’s solution) 1-5 drops orally every eight hours. Steroids such as prednisolone (2 mg/kg) may also be administered in the severely thyrotoxic child to decrease deiodination of T4 to T346. It is not expected for all of these medications to be administered in the ED, as the primary goal is to stabilize the patient and decrease the heart rate prior to transfer.
General Interventions
General interventions in the critically ill neonate include cardiac monitoring, continuous pulse oximetry, and Foley catheterization with hourly measurement of urine output. The child who has persistent vomiting, abdominal distention, or evidence of intestinal obstruction may benefit from placement of a nasogastric tube.
Critically ill newborns often require intubation either for airway protection or to decrease the work of breathing in profound shock. Premature babies may need to be intubated with a 2.5 mm endotracheal tube, while full-term babies can typically be intubated with a 3.0 endotracheal tube. The Broselow tape is more accurate than the typical age-based formula of (16+age in years)/4 in determining the size of theendotracheal tube.54
Deep suctioning of the nasopharynx can be extremely helpful in infants with bronchiolitis. Wheezing may respond to aerosols, and racemic epinephrine may be more effective than beta-agonists.77,78 The debate regarding steroids for bronchiolitis continues. While some patients may benefit from steroid use, it is not clear that steroids should be routinely used for management.79,80 Because of the risk of bronchiolitis-related apnea, most texts recommend hospital admission for infants less than 3 months of age, those who have been previously intubated, or those who have cardiac disease.81
In the cyanotic infant, methemoglobin levels of 25%- 30% will impair oxygen delivery and should be treated with 1-2 mg/kg IV of methylene blue.13
Fluids And Pressor Support
ED management of the newborn in shock includes volume repletion with normal saline in 20 cc/kg boluses to treat shock. If the etiology of shock is unclear, and congenital heart disease is suspected, then it may be prudent to start with 10 cc/kg boluses. If the child appears to be in septic shock, be aggressive in fluid administration. One study showed that children who receive greater than 40 mL/kg of normal saline in the first hour of care do better than those who receive less than 20 mL/kg.82 If the patient’s blood pressure and mental status do not improve with a total of 60-80 cc/kg of normal saline, then additional measures are indicated.
In the presence of hemorrhage, packed red blood cells should be given, starting with 5-10 cc/kg. For septic or cardiogenic shock, the initial drug of choice is dopamine, starting with 6-10 mcg/kg/min. Central venous access may be useful since tissue necrosis can result from peripheral pressor infiltration.9
If intravenous access cannot be obtained in a critically ill neonate, start an intraosseous line, preferably in the proximal tibia. Fluids and most resuscitation drugs can be given by this route. A pressure bag can ensure adequate flow rates if the child is profoundly volume-depleted.
Glucose Replacement
Hypoglycemia in the newborn is defined as a plasma glucose level of less than 30 mg/dL.83 However, symptomatic patients with blood sugars less than 60 mg/dL should be treated, because infants and newborns have low glycogen stores.84 To treat hypoglycemia in neonates, start with 2 cc/kg of D10 solution and repeat as needed.
Medications For Seizures
Benzodiazepines are the first line of treatment for neonatal seizures, followed by phenobarbital, fosphenytoin, or phenytoin.43 Lorazepam is preferred as it causes less respiratory depression than diazepam and provides a greater duration of anti-seizure activity.45 Phenytoin has a depressive effect on the newborn myocardium and has an unpredictable rate of metabolism due to immature hepatic function.45 Pyridoxine (50-100 mg IV) or lidocaine may be used if refractory seizures are present. (See Table 6.) If the seizure is a result of an electrolyte abnormality such as hyponatremia, hypocalcemia, or hypomagnesemia, rapidly replete these deficiencies. Hyponatremia can be corrected with either normal saline (0.9%) boluses or alternatively with 5-7 mL/kg IV of 3% saline (this can be administered as a bolus given over 10 minutes). If the patient has hypocalcemia (plasma calcium < 7.0 mg/dL), administer 100-300 mg/kg IV of 10% calcium gluconate. In cases of hypomagnesemia (serum magnesium < 1 mEq/L), 0.1-0.3 cc/kg of 50% magnesium sulfate should be given intravenously or intramuscularly. Consider the need for antibiotics or antiviral medication in infants with seizures.
Medications For Cardiac Disturbances
If ductal-dependent congenital heart disease is suspected based on central cyanosis in the first 2-3 weeks of life, treat the infant empirically. Begin an infusion of prostaglandin E1 (PGE1) at a rate of 0.005 mcg/kg/min and titrate upwards to a maximum of 0.1 mcg/kg/min. Prostaglandin is a potent vasodilator and will immediately begin to re-open the ductus. Improvement is usually seen within 15 minutes; however, the practitioner should be prepared to intubate since apnea is a side effect of PGE1. Other complications of prostaglandin use include fever, hypotension, and seizures. There are few pediatric studies on the management of congestive heart failure; therefore, most of the management regimens have been based on the adult literature.85,86
Furosemide (1 mg/kg) is still considered a good initial agent, but it may need to be combined with digoxin, morphine, nitrates, dobutamine, or dopamine based on the clinical circumstances. Beta-blockers such as carvedilol should be used with caution as they have a high incidence of hypotension and bradycardia.86 Angiotensin-converting enzyme inhibitors may have a role in pediatric congestive heart failure; however, data are limited,86 and it may be helpful to contact a pediatric cardiologist prior to initiating these agents.
Supraventricular tachycardia is the most common symptomatic dysrhythmia in infants and children. Treatment depends on whether or not the child is stable. If the newborn is in extremis, immediately cardiovert the child with 0.5-1.0 J/kg. In the stable patient, vagal maneuvers such as crushed ice in a plastic bag applied to the infant’s face can prove successful.87 If this fails, give adenosine 0.1 mg/kg followed by a normal saline flush of 5 cc. If unsuccessful, administer an increased dose of 0.2 mg/kg.9 Further interventions are best conducted after consultation with the pediatric cardiologist. Options may include digoxin (10 mcg/kg IV initial load, second dose in six hours, and third at 24 hours) and procainamide (10-15 mg/kg IV over 30-45 minutes). Verapamil should not be used in children under 1 year of age as cardiovascular collapse and death can occur.88
Antibiotics/Antivirals
Children at risk for sepsis benefit from early empiric antibiotics. Antibiotics should cover the more common pathogens in this age group. Empiric regimens may include a combination of ampicillin 100 mg/kg IV and a thirdgeneration cephalosporin such as cefotaxime 50 mg/kg IV. Another traditional combination is ampicillin 100 mg/kg IV and gentamycin 2.5 mg/kg IV. Both of these regimens are effective against Listeria, E. coli, and Group B Streptococcus. Some specialists add vancomycin 10 mg/kg IV to cover drug-resistant organisms, especially if the cerebrospinal fluid is visibly purulent.89
While a recent study of 120 neonates found no blood or cerebrospinal fluid cultures positive for Listeria,22 many authorities still believe that antibiotic coverage against Listeria remains indicated. If the cerebrospinal fluid results are consistent with meningitis, a third-generation cephalosporin with good central nervous system penetration, such as cefotaxime, is recommended, with some specialists expanding coverage with vancomycin depending on the local incidence of penicillin-resistant Pneumococcus.90 The American Academy of Pediatrics Committee on Infectious Diseases suggests that dexamethasone 0.15 mg/ kg IV be considered for children with pneumococcal meningitis. 91 Recent data in adults show that dexamethasone given shortly before or concurrent with antibiotics improves outcomes in bacterial meningitis.92
Begin acyclovir (20 mg/kg q8h IV) if there is a positive maternal history of herpes, a vesicular rash, focal neurologic findings, cerebrospinal fluid pleocytosis, or elevated cerebrospinal fluid protein without organisms on Gram’s stain.93
Metabolic Interventions
The most important ED intervention in the neonate with an inborn error of metabolism is to rehydrate with normal saline boluses. This is followed by a maintenance fluid of D10 0.45% normal saline at 1.5-2.0 times the normal rate to promote excretion of the toxic metabolites.38 Insert a Foley catheter and target a urine output of 1-2 cc/kg/h. Correct hypoglycemia and administer a continuous glucose infusion. Discuss the need for sodium benzoate (for urea cycle defects), sodium bicarbonate, or sodium phenylacetate administration with the pediatric endocrinologist. Dialysis may be necessary to decrease serum organic acids, and patients should be admitted to the neonatal or pediatric intensive care unit for further management.
If the child has evidence of congenital adrenal hyperplasia, resuscitate with boluses of normal saline if the child has evidence of shock or volume depletion. Consultation with a pediatric endocrinologist may be helpful in deciding on the maintenance fluids. Administer hydrocortisone 25 mg IV, then 25-50 mg/m2/d divided every 6-8 hours (approximately 25 mg every 6-8 hours in full-term newborns).18 (The body surface area is equal to the square root of the: [height in centimeters multiplied by the weight in kilograms] divided by 3600.) Hyperkalemia typically responds to fluid replacement alone; however, severe hyperkalemia, especially if dysrhythmias are present, should be treated with 10% calcium gluconate (100 mg/kg), sodium bicarbonate 1 mEq/kg, insulin 0.1 unit/kg with D10 3-10 cc/kg, and kayexalate.18 Monitor serum glucose closely as these patients are frequently hypoglycemic.
At times children with neonatal thyrotoxicosis will present in a hypermetabolic state. Management includes propanolol 2 mg/kg/d divided three times a day to decrease the tachycardia and hypermetabolic state. Production of thyroid hormone can be decreased with propylthiouracil 5-10 mg/kg/d or methimazole 0.5-0.7 mg/kg, followed one hour later by potassium iodide (Lugol’s solution) 1-5 drops orally every eight hours. Steroids such as prednisolone (2 mg/kg) may also be administered in the severely thyrotoxic child to decrease deiodination of T4 to T346. It is not expected for all of these medications to be administered in the ED, as the primary goal is to stabilize the patient and decrease the heart rate prior to transfer.
General Interventions
General interventions in the critically ill neonate include cardiac monitoring, continuous pulse oximetry, and Foley catheterization with hourly measurement of urine output. The child who has persistent vomiting, abdominal distention, or evidence of intestinal obstruction may benefit from placement of a nasogastric tube.
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