Welcome (Back) to NICU!

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Objectives

• Refresh your memory on the NRP algorithm
• Recognize equipment setup and preparation for key procedures
• Demonstrate technical proficiency with neonatal intubation, UVC placement, and needle thoracentesis.
• Practice your skills using simulated delivery room scenarios

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Agenda(ish)

08:00–09:30 | NRP Refresher

09:30–10:30 | Procedural Skills Stations: Intubation, UVC, Needle Thoracentesis

10:30–12:00 | Put it all together: simulation scenarios

12:00–13:00 | Lunch + Travel to Clinical Sites

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Some General NICU Tips: Day to Day Work

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• Most units will have patients assigned to the resident, the fellow and NPs. Take responsibility for your patients, but don’t be afraid to ask for help.

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• NICU babies need clustered care: you may be asked to defer or “group” your physical exam with other care team members.

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• Ensure your CC notes are accurate and uptodate! Beware mistakes when using the “copy” function!

Some General NICU Tips: Rotation Experience

• We work in a large multidisciplinary team with many different learners. Please don’t be afraid to advocate for yourself and your learning needs (appropriate patients, procedures, etc)
• Be prepared- make sure you have read relevant policy & procedure documents
• Make yourself available, especially when on call!
• Some patients/procedures are only allowed to be completed by senior practitioners (think microprems, unstable patients, etc…)
• Guidelines exist outlining the specifics of this- see your Objectives documents for links

PLEASE meet with your preceptors early to discuss your goals and learning objectives for the rotation

They can help advocate for you!!

Some General NICU Tips: Rotation Experience

SEND US YOUR EPAs!! (You can send them to neos, fellows, NPs, transport team members, charge nurses, etc, etc…)

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Rotation Education: Baby Talks

What: “Baby Talks” aims to gather residents rotating through NICU to discuss relevant topics at a general pediatric level.

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When: Every Friday from 1:30- 2:30pm

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Where: Zoom!

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More info:

• These sessions are for your learning and should be resident led. A neo/NICU fellow will be scheduled to help facilitate.
• These are not meant to be formal presentations (i.e. no powerpoint!)
• The goal is to review 2 topics per week; aiming for 20-30min discussion per topic.
• Please decide a presentation schedule amongst yourselves.
• See your rotation intro email from Melissa Meaver for suggested topics and the Zoom link.

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NICU Resources

• Neonatal Perinatal Medicine Pediatric Education Website
• Objectives Documents
• Schedules and Unit Events
• Policy and Procedure Documents
• Suggested Reading Materials
• Orientation PPTs (including this one)

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• Find it here:
• https://sites.google.com/a/ualberta.ca/pediatric-education-external-learners---neonatal/resources-for-learners?authuser=0
• Link can also be found in your rotation intro email from Melissa Meaver

NICU Resources

• Toronto Residents Handbook of Neonatology
• FREE PDF!!!
• Meant to be used as a quick on-call reference for residents, study guide for final year residents, and clinical resource for general paediatricians.
• 18 chapters that cover core topics in neonatal care
• Canadian Paediatric Society position statements form the foundation of the content. In the absence of CPS statements, national / international guidelines, hospital-specific guidelines, and expert opinion were used.
• Find it here:

https://torontocentreforneonatalhealth.com/wp-content/uploads/2022/10/Toronto-Residents-Handbook-of-Neonatology-Oct-2022.pdf

Rotation Contacts

Program Administrator:

Melissa Meaver

pedsneo@ualberta.ca

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Rotation Coordinator:

Dr. Ijab Khanafer-Larocque

Ijab.Khanafer@albertahealthservices.ca

Neonatal Resuscitation

Resident Refresher

Weiner, G. M., & Zaichkin, J. (2021). Textbook of neonatal resuscitation. 8^th edition. Elk Grove Village, IL: American Academy of Pediatrics.

Preparation

Delayed Cord Clamping

• Delay cord clamping for 30-60 seconds for most vigorous term and preterm newborns
• may place skin-to-skin with mom
• may cover with towel or plastic

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• No DCC if placental circulation is disrupted (abruption, bleeding placenta previa, bleeding vasa previa, cord avulsion)

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Initial Steps

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Initial Steps

• Provide warmth
• Position head and neck
• Suction if needed
• Dry (or cover in plastic)
• Stimulate

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• ASSESS BREATHING!
• If breathing→ assess heart rate
• If apneic→ START PPV

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Assess HR

• Palpation of the umbilical cord is less reliable and less accurate than auscultation

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• Auscultation can be difficult
• consider applying pulse oximeter +/- cardiac leads

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• If starting PPV→ apply monitors

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PPV

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Oxygen

• Initial FiO2 for PPV
• ≥ 35 weeks’ GA = 21%�< 35 weeks’ GA = 30%

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• Always use pulse oximetry to guide oxygen concentration

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• IF DOING COMPRESSIONS→ increase to 100% oxygen

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https://www.gehealthcare.com/-/jssmedia

Target Saturations

MR SOPA - Ventilation Corrective Steps

Intubation

Yellow= YES

Purple= PROBLEM

Chest Compressions

• Intubation STRONGLY recommended before starting compressions
• Use 2-thumb technique
• Use 100% oxygen
• Head-of-bed compressions

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• 3:1 compression to breath ratio
• One-and-2-and-3-and-breathe- and.....

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THIS IS DIFFERENT THAN PALS!!!

Medications

• Epinephrine
• IV/UVC preferred (0.2 ml/kg)
• flush with 3ml NS
• can repeat q3-5mins

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• ET x 1 while achieving intravascular access (1 ml/kg)

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• Normal saline or type-O Rh-negative blood (10ml/kg)

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Prem Considerations

• Maintain temperature (ideal 36.5- 37.5 °C)
• ↑ room temp to 23-25°C
• Use a hat
• If < 32 wks, use a thermal mattress and cover baby in plastic wrap/bag
• (at RAH- <29 weeks)

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• Consider CPAP if baby is breathing immediately after birth
• Starting FiO2 30%- titrate as tolerated/necessary

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References

• Canadian Pediatric Society Newborn Resuscitation: The Science of NRP 7th Edition

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• Weiner, G. M., & Zaichkin, J. (2021). Textbook of neonatal resuscitation. 8^th edition. Elk Grove Village, IL: American Academy of Pediatrics.

SKILL STATIONS

Neonatal Intubation

• "Neonatal Tracheal Intubation" by Lindsay Johnston for OPENPediatrics - YouTube

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Intubation

Yellow= YES

Purple= PROBLEM

Umbilical Line Placement

• Catheter Size:
• <1500g- 3.5Fr
• >1500g- 5Fr

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• Catheter Lumens
• UAC: single lumen
• UVC: depends (single, double, triple)

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• Insertion Depth:
• UAC: (3x BW)+ 9 + length of cord
• UVC: (UAC depth)/2+ length of cord

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https://vimeo.com/57453941

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THERE’S AN APP FOR THAT!

insertion depth calculator

Umbilical Line Placement- UVCs

Umbilical Line Placement- UVCs

Umbilical Line Placement- UACs

Umbilical Line Placement- UACs

UVC Suturing

UVC Suturing- Purse String

Line Securement

What…. was that?

QR codes to videos of everything we just talked about available:

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• On the learner website (linked at beginning of this presentation/in your email from Melissa)

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• In the Learners Offices at all sites

Sooo.. you want me to do THAT procedure to get emergency access in a code??

Emergency UVC Insertion

1. Gather supplies
1. Single lumen UVC catheter (3.5Fr for <1500g; 5Fr for >1500g)
2. UVC “kit” (cleaning swabs, cord tie, scalpel, tegaderm/tape)
3. Normal saline flush
1. Prepare the line
1. Attach a stopcock or neutron valve (to create closed system) if available
2. Attach the normal saline flush
3. Flush the line
1. Prepare the infant
1. Clean the cord
2. Tie the cord at the base of the cord, above the skin
3. Cut the cord about 1 cm above the skin, between cord tie and clamp

Emergency UVC Insertion

4) Insert the line

• Insert to a depth of 3-5 cm (wherever you get easy blood return)

5) Secure the line

• Using tape or a tegaderm to the abdomen
• Line is high risk for dislodgement- needs careful monitoring

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Needle Thoracentesis

• https://www.youtube.com/watch?v=eYO6zp4V3uA

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Evaluation