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salameh101

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  • First name
    khalil
  • Last name
    salameh
  • Occupation
    neonatology
  • Affiliation
    hmc
  • Location
    doha-qatar

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  1. .ETT c&s within first 12-24 , Eye swab c&s especially for gram negative. any blood c&s should be treated until proved otherwise. CRP SINGLE READING IS NOT SIGNIFICANT RATHER THAN THE TREND
  2. Nurses in LR and OT should NRP and training to do basic life support(AIRWAY AND O2 BY BAG) till neonatology team reach . The other alternative neonatologist to be in LR,OT FOR 24 HR which it’s not possible
  3. a. Suspicion of sepsis could have been anticipated earlier on view of reduction of platelet count and the progressive metabolic acidosis. b. Ventilatory devises are a potential source of organisms c. The insidious onset is a common pathophysiologic feature of some organism and could reflect on a lack of early interpretation of infant septic behavior. d. All positive cultures are to be taken seriously and infants (particularly prematures) treated empirically until further support to discontinue medications becomes available. e. CRP as part of sepsis work-up, should be performed more than once to be utilized as a reliable indicator. f. CBC picture with leukopenia and neutropenia with feeding intolerance and upper GIT bleeding are all potential signs of sepsis. g. Placental histopathology and culture should be requested in cases where maternal infection may be the source of neonatal sepsis. h. HVS should be requested in infants where GBS is suspected but not proven. Use of antibiotics: a. Highly potent antibiotics such as meropinum should not be used until discussed with team leaders or infectious disease personnel. b. Targocid use for Staph hemolyticus sepsis should be observed closely as the organism is understood to change it’s sensitivity pattern in vivo. In this scenario switching to vancomycin may be appropriate. c. The proper time interval between ampicillin and gentamicin IV infusion is > 1 hour.
  4. Normal’ blood pressure should be defined as the pressure, which ensures adequate organ perfusion. The normal values will depend on gestational age, birth weight and postnatal age. They defined hypotension as less than the 10th centile for birth weight and postnatal age BP. PERFUSION. PH AND LACTIC ACID. PULSE VOLUME QUALITY KIDNEY FUNCTION AND URINE OUTPUT. VENTRCULAR CONTRACTION AND CARDIAC OUTPUT. CVP NORMAL 3-9 blood pressure less than the gestational age does not necessarily need to be treated. Global assessment of cardiovascular status and intervention for hypotension restricted to infants with poor perfusion may have good clinical outcomes and warrants further evaluation. The treatment of neonatal hypotension should be based on an overall assessment of cardiovascular status of the infant and not blood pressure alone. The heart rate, peripheral perfusion and urine output should be considered in addition to blood pressure, elevated lactate concentration on blood gas analysis indicates low tissue perfusion. Echocardiographic evaluation can serve as useful adjunct, but is not readily available in most neonatal units.
  5. Pre-ductal and post-ductal pulse O2 saturation (SpO2) monitors (to detect R → L shunting at ductus arteriosus). A difference of ≥10% suggests marked pulmonary hypertension or PDA dependent leison. Pre-ductal and post-ductal pulse O2 saturation (SpO2) can be used as screening for cyanotic heart disease for NB befor discharge hom fro postnatal ward.
  6. Regular prophylactic IM vitamin K usualy given in LR shortly after delivery ,subgaleal hrg may diagnosed later,but in acase that you diagnsed subgaleal hrg befor regular V K,should be given IV
  7. Thanks for your comment; 1-Coagulation screen (INR, PTT, PTT, fibrinogen, d-dimers) every 4-8 hours (2) DIAGNOSIS. if abnormal vitamin k or FFP will be given. (Treat congenital or acquired coagulation problem)( F MANAGAMENT) For pain management we have protocol for pain assessment and management for all babies in NICU.
  8. NICU Guidelines --- Women’s Hospital -HAMAD MEDICAL CORPORATION-DOHA-QATAR Effective Date; March 1, 2010 Revision Date; March 1, 2012 Subgaleal Hemorrhage Guidelines Introduction Subgaleal hemorrhage (SGH) is a collection of blood in the soft tissue space between the galea aponeurotica and the periosteum of skull. This hemorrhage is caused by rupture of the emissary veins, which are connections between the dural sinuses and the scalp veins. This potential space extends forward to the orbital margins, backward to the nuchal ridge and laterally to the temporal fascia, and, in term infants, may hold as much as 260 ml of blood (which is almost equivalent to the baby’s blood volume). SGH is a rare, potentially lethal condition. It most commonly occurs following a difficult vacuum or forceps-assisted birth. The prevalence of moderate-to-severe SGH is reported as 1.5 per 10,000 births. Once bleeding into this space starts, it can be difficult to control because of subsequent blood loss and a resulting coagulopathy. SGH, therefore, can lead to severe hypovolemia, and up to 25% of babies who require neonatal intensive care for this condition can die. At Risk Newborns: 1. Forceps and vacuum delivery 2. Vacuum extraction with more than 3 pulls or pop-offs of a vacuum extractor 3. Any failed instrumental delivery Signs and symptoms of SGH: The signs may be present at birth or may not become clinically apparent until several hours or up to a few days following delivery. 1. SGH usually presents with nonspecific symptoms such as pallor, grunting (as a result of metabolic acidosis), tachypnea, or hypotonia. 2. Diffuse fluctuating swelling of the head; the swelling is usually diffuse, crosses suture lines, shifts dependently when the infant's head is repositioned and indents easily on palpation. The ears are pushed forward when there is a large amount of fluid present. In some cases the swelling is difficult to distinguish from the edema of the scalp. 3. Increasing HC 4. Evidence of hypovolemic shock (lethargy, pallor, poor perfusion, hypotension, tachycardia, increased respiratory rate, metabolic acidosis, decreased urinary output) 5. Prolonged bleeding 6. Seizures Diagnosis Diagnosis of SGH is clinical. The scalp is boggy (feels like a water balloon, fluid is firm to fluctuant with ill defined borders, may have crepitus or waves and shifts dependently when the infant’s head is repositioned). SGH may be misdiagnosed as cephalohematomas or caput succedaneum.  Cephalhematoma is the collection of blood under the periosteum and does not cross the suture lines. Cephalhematomas are firm masses that will resolve in 2 weeks to 6 months.  Caput succedaneum is localized scalp edema that is the result of venous congestion from the pressure of the head applied to the dilating cervix. The edema can cross the suture lines. Caput does not increase in size over time and resolves several days after birth. Feature Caput succedaneum Cephalhematoma Subgaleal hemorrhage Location At point of contact; can extend across sutures Usually over parietal bones; does not cross sutures Beneath epicranial aponeurosis; may extend to orbits, nape of neck Characteristic findings Vaguely demarcated; pitting edema that shifts with gravity Distinct margins; initially firm, more fluctuant after 48 h Firm to fluctuant; ill-defined borders; may have crepitus or fluid waves Timing Maximal size and firmness at birth; resolves in 48-72 h Increases after birth for 12-24 h; resolution over 2-weeks to 6 months Progressive after birth; resolution over 2-3 weeks Volume of blood Minimal / No bleeding Rarely severe May be massive, especially if there is an associated coagulopathy Investigations: 1. CBC, hematocrit, when SGH is suspected, hemoglobin measurement should be performed as soon as possible and should be monitored every 4–8 hours. 2. Coagulation screen (INR, PTT, PTT, fibrinogen, d-dimers) every 4-8 hours. 3. CT scan or MRI of the head. MRI scan is the preferred method of imaging 4. Radiographs of the skull can also be useful to identify underlying fractures Management of SGH 1. The first step in the management of SGH is to screen all at-risk newborns as recognition and supportive care can improve survival and outcome 2. Newborns at risk for SGH: a. Can remain with their mother as long as their vital signs are normal and the infant is not demonstrating any signs of distress. Those infants should be observed for symptoms for 24-48 hours before discharge. b. Monitor vital signs at birth, 2, 4 and 6 hours of life, then every 4 hours for all babies after difficult vacuum extractions. c. Measure HC immediately after birth and then every 4 hours. 3. Newborns with SGH; early recognition of SGH and the institution of supportive care such as blood transfusion, volume support, and coagulation factors in the presence of DIC, may be useful. a. Admit to IC/NICU b. Monitor vital signs hourly for the first 4 hours then 2-4 hours depending on the severity of the case. c. Assess, color, perfusion, pain and appearance of scalp with vital signs d. Measure HC immediately after birth and then every 4 hours. If an increase in the HC is noted, then measure HC every 2 hours. The HC increase about 1 cm with each 40 ml of blood deposited in the subaponeurotic space. e. Treat anemia/hypovolemic shock with blood volume replacement. f. Treat congenital or acquired coagulation problem g. Interventions to minimize blood loss: i. Avoid IM injections when possible. ii. Avoid percutaneous arterial punctures if possible. iii. Provide prolonged pressure after venipuncture, heel-stick, or arterial stick. iv. Minimize invasive procedures as much as possible v. Gentle suction only when needed. vi. If intubated, do not deep suction. h. Ensure the availability of 1 unit of cross matched packed RBCs in the blood bank in case transfusion is needed. i. Pressure wrapping of the head has been advocated by some, but the large subaponeurotic space is difficult to wrap; wrapping might be disadvantageous if cerebral edema is present. Prognosis: Prognosis depends on the severity of the hemorrhage; with early recognition and aggressive volume resuscitation full recovery is possible and long-term outlook for survivors is good. The subaponeurotic space may hold as much as 260 ml of blood, therefore can lead to severe hypovolemia and cause death in 20% to 60% of patients. The most important risk factors for death in babies with SGH are:  Decrease in hematocrit >25% of the baseline value at birth requiring urgent blood transfusion in the first 12 hours.  Hhypovolemic shock  DIC  Association with significant birth asphyxia  Intracranial hemorrhages are also more frequently associated with SGH (~50% in one study). References 3. Chadwick LM, Pemberton PJ, Kurinczuk JJ. Neonatal subgaleal hematoma: associated risk factors, Zcomplications and outcome. J Paediatr Child Health. 1996; 32(3):228-32. 4. Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome-- radiological findings and factors associated with mortality. Am J Prinatol. 2006;23(6): 41-8. 5. Hall SL. Simultaneous occurrence of intracranial and subgaleal hemorrhages complicating vacuum extraction delivery. J Perinatol. 1992;12(2):185-7. 6. Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ. 001; 164(10):1452-3. 7. Ng PC, Siu YK, Lewindon PJ. Subaponeurotic hemorrhage in the 1990s; a 3-year surveillance. Acta Paediatr. 1995; 84(9):1065-9.
  9. iF the pt dischrge home on room air HB of 8 gram/dl or more isd safe,again pt to discharge on iron,folow upp 1-2 wk in OPD is recomended .
  10. in acase of chronic hemolysis like ABO OR RH you may discharge the pt on Iron and Folic Acid,Folow upp in OPD is important to checck HB AND SB.
  11. I think the picc line should be insertd as soon as posible for any baby who will not be on full oral feedin for 7-10 day,s because you need a good perepheral vein befor all good perepheral vein used . This what we do in our unit.
  12. •5 years back the Light Emitting Diode devices can provide higher irradiance as compared to conventional phototherapy. •but now Light Emitting Diode (LED) phototherapy units are at least as efficacious and as safe as Compact Fluorescent please folw the link Tube (CFT) phototherapy units in healthy term and late-preterm neonates with non-hemolytic jaundice. http://medind.nic.in/ibv/t10/i2/ibvt10i2p131.pdf(Light-emitting Diodes versus Compact Fluorescent Tubes for Phototherapy in Neonatal Jaundice:) A Multi-center Randomized Controlled Trial
  13. Because of the low incidence of meningitis in the newborn infant with negative blood culture results, clinicians may elect to culture the CSF of only those infants with documented or presumed sepsis. However, recent data in large numbers of patients show a 38% rate of culture-positive meningitis in neonates with negative blood culture results and suspected sepsis. Therefore, a lumbar puncture should be part of the evaluation of an infant with suspected sepsis. Intrpartum antibiotic may cause negative culture in some pt with real sepsis or meningitis.
  14. Cochrane review(2008) of early rHuEPO administration (starting before the 8th day of life) found a reduction in the number of transfusions, the volume of packed red blood cells given, and the number of donors required, but reported a significant increase in the frequency of severe (stages III-V) retinopathy of prematurity
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