ACoRN Workbook “2012 Update” · ACoRN Workbook “2012 Update” _____ Name: ACoRN Neonatal Society ... SpO 2 Degree of desaturation Stable Circulatory instability or anemia >

ACoRN Workbook – version 1.4.01 February 2013 (2012 Update) © ACoRN Neonatal Society

ACoRN Workbook

“2012 Update”

_____________________________________ Name:

ACoRN Neonatal Society Société néonatale “ACoRN”

A Canadian non-profit Society Vancouver, British Columbia

www.acornprogram.net



The ACoRN Process



The Resuscitation Sequence

Ensure 100% O2, positive pressureventilation, chest compressions, and

epinephrine correctly administered (^) Repeat epinephrine Ensure vascular access Consider volume expansion Draw venous blood gas

Transillumination Consider needle aspiration

Call for help Access equipment Provide warmth Position Clear airway (^) Stimulate Administer O2 as needed

Establish monitors:- pulse oximetry (pre-ductal)- cardiorespiratory- blood pressure

Ineffective breathing HR < 100 bpm

No

Yes

No

HR > 60 bpm Initiate chest compressions

(^) with 100% O2

Administer epinephrine (^)

Consider intubation at any point indicated by a caret (^)

HR > 100 bpm

HR < 60 bpm

HR < 60 bpm

HR < 60 bpm

Initiate/continue positive pressure ventilation (^)

Consider pneumothorax

HR < 60 bpm

ACoRN PrimarySurvey

Ineffective breathing Heart rate < 100 bpm Central cyanosis

Yes


The Respiratory Sequence

Vascular access Chest radiograph Blood gas Consider consultation

Respiratory Laboured respiration * Respiratory rate > 60/min * Receiving respiratory support *

Recheck patent airway/breathing Administer O2 as needed to maintain SpO2 88-95% Establish/continue monitors:

- pulse oximetry (pre-ductal)- cardiorespiratory- blood pressure- oxygen analyzer

Calculate ACoRN Respiratory Score if spontaneously breathing

Yes

No

Respiratory Sequence

Focused history Physical examination Review diagnostic tests done Establish working diagnosis

Consider chest drain and followup chest radiograph

Consider surfactant

RDS Pneumothorax (1) TTN Mild respiratory distress

Reassess diagnosis and management if unresolved within 4 hours

Mild respiratory distress (ACoRN score < 5) lasting < 4 hours

Severe respiratory distress (score > 8) Apnea or gasping Receiving ventilation

Moderate respiratory distress (score 5 to 8) Persistent or new respiratory distress

Intubate if not already intubated Optimize ventilation

Consider/adjust respiratory support (CPAP or PPV)

Repeat ACoRN Respiratory Score if spontaneously breathing Optimize oxygenation Optimize respiratory support (adjust ventilator/CPAP settings, wean, or discontinue)

Problem List

Supportive care

Aspiration Pneumonia PPHN Other

(1) drainage of a symptomatic pneumothorax takes precedence over returning to the Problem List


The Respiratory Score (p. 3-7):

Score 0 1 2

Respiratory rate 40 to 60/min 60 to 80/min > 80/min

Oxygen requirement1 none ≤ 50% > 50%

Retractions none mild to moderate

severe

Grunting none with stimulation continuous at rest

Breath sounds on auscultation easily heard

throughout decreased barely heard

Prematurity > 34 weeks 30 to 34 weeks < 30 weeks

1 A baby receiving oxygen prior to the setup of an oxygen analyzer should be assigned a score of “1”

Adapted from Downes JJ, Vidyasagar D, Boggs TR Jr, Morrow GM 3rd. Respiratory distress syndrome of newborn infants. I. New clinical scoring system (RDS score) with acid-base and blood-gas correlations. Clin Pediatr 1970; 9(6):325-31. Total score: Mild: < 5; Moderate: 5 to 8; Severe: > 8 Interpretation of blood gas results (p. D-4):

1. Normal, acidosis or alkalosis? 2. Respiratory, metabolic, mixed or

compensated?

Blood gas values (p. D-4):

pH PCO2 BD Interpretation

↓ ↑ Normal Respiratory acidosis

↓ Normal ↑ Metabolic acidosis

↑ ↓ Normal Respiratory alkalosis

↑ Normal ↓ Metabolic alkalosis

Normal Acceptable values for acute respiratory distress

pH 7.35 to 7.45 7.25 to 7.40

PCO2 35 to 45 mmHg 45 to 55 mmHg

BD - 4 to + 4 mmol/L


The Cardiovascular Sequence


Signs of circulatory stability / instability (p. 4-8):

Tolerance to various degrees of desaturation in newborns with cyanotic heart disease, assuming normal hemoglobin levels and cardiac output (p. 4-35):

SpO2 Degree of desaturation Stable Circulatory instability or anemia

> 75% mild to moderate usually well tolerated usually tolerated

65 to 75% marked usually tolerated not well tolerated

< 65% severe poorly tolerated poorly tolerated

Sign Stable Unstable

Level of alertness, activity and tone alert, active and looking well,

normal tone listless, lethargic and/or

distressed, decreased tone

Skin colour, and temperature well perfused, peripherally warm pale, mottled, peripherally cool

Capillary refill time ≤ 3 seconds centrally and peripherally

> 3 seconds

Pulses easy to palpate weak, absent

Mean blood pressure ≥ gestational age in weeks < gestational age in weeks

Heart rate 100 to 160 bpm > 160 bpm

Urine output ≥ 1 mL/kg/hour < 1 mL/kg/hour


The Neurology Sequence


Therapeutic Hypothermia / Normothermia for HIE

The following Alerting Signs identify babies who require observation for the development of hypoxic ischemic encephalopathy.

When indicated, therapeutic hypothermia should only be initiated after: completion of Neonatal Resuscitation (NRP), and the ACoRN Primary Survey and Sequences consultation with the clinical transport coordinator and following a strict protocol.

Therapeutic normothermia involves active thermal management to avoid hyperthermia. The aim of therapeutic normothermia is to maintain the axillary temperature between 36.0oC and 36.5oC.

Criteria for Initiation of Therapeutic Hypothermia (Appendix F): The following must all be met prior to initiating therapeutic hypothermia

NRP and ACoRN Sequences completed

At risk of HIE Alerting Sign present

Moderate to severe HIE present as per the Clinical Assessment of Neurological Dysfunction table

Gestational age is ≥ 35 weeks

Postnatal age is ≤ 6 hours

No absolute contraindications (e.g. cardiorespiratory instability, severe coagulopathy, etc)

Tertiary level consultation obtained


Clinical assessment of neurological dysfunction (p. 5-9, F-5):

The presence of moderate or severe HIE is defined as seizures or signs present in at least three of the six categories below, or by the regionally recommended scoring system.

Category Mild Moderate Severe

Level of alertness “hyperalert” lethargy stupor or coma

Spontaneous activity normal decreased activity no activity

Posture mild distal flexion

arms flexed, legs extended

arms and legs extended

Tone normal hypotonic flaccid

Primitive reflexes weak suck, strong Moro

weak suck, incomplete Moro

absent suck, absent Moro

Autonomic (one of) Pupils Heart rate Respirations

dilated reactive

tachycardia

normal

constricted

bradycardia

periodic breathing

dilated or non-reactive

variable heart rate

apnea

Seizures none absent or present absent or decerebrate Adapted from Sarnat HB et al: Neonatal encephalopathy following fetal distresss: A clinical and encephalographic study. Arch Neurol 33:695,1976. Jitteriness versus Seizures (p. 5-4):

Adapted from Volpe JJ. Neurology of the Newborn. 5th Edition. Philadelphia: WB Saunders Company, 2008 Documentation of abnormal movements (p. 5-31):

Time/ duration

Suppress by holding

Origin/ spread

Eye/mouth movements

Level of alertness Autonomic changes

Other signs

09:00 h 20 sec

No Right arm, then all extremities

Eyes deviated to left Normal crying, auditory and visual responses when not seizing

No No

Observation Jitteriness Seizures

Abnormal gaze or eye movement no yes

Movements exquisitely sensitive to stimuli yes no

Predominant movement tremor clonic jerking

Movements cease with passive flexion yes no

Autonomic changes (e.g., tachycardia, increase in blood pressure, or apnea)

no yes


The Surgical Conditions Sequence


The Fluid & Glucose Management Sequence


Guide for enteral and intravenous fluid administration (p. 7-4):

Postnatal age Baseline milk intake (if not breastfed on cue)

Baseline intravenous intake (if not feeding)

Day 1 (72 mL/kg/day)

up to 6 mL/kg1 q 2h (9 mL/kg q 3h)

D10%W at 3 mL/kg/hour


up to 8 mL/kg q 2h (12 mL/kg q 3h)

D10%W at 4 mL/kg/hour



D10%W with 20 mmol/L of NaCl at 5 mL/kg/hour

≥ Day 4 (144 mL/kg/day)


D10%W with 20 mmol/L of NaCl at 6 mL/kg/hour (± other electrolytes)

1 If hypoglycemic, start with 8 mL/kg q 2h.

Suggested steps for increasing glucose intake if blood glucose checks remain < 2.6 mmol/L or < 47 mg/dL (p. 7-15):

Steps Enterally fed IV dextrose infusion

Baseline Breastfeed on cue, or

Feed every 2 to 3 hours

D10%W, 3 mL/kg/hour (5 mg/kg/minute of glucose)

Step 1 Feed measured volume 8 mL/kg every 2 hours, or

Start IV dextrose infusion at baseline

D10%W, 4 mL/kg/hour (6.7 mg/kg/minute of glucose)

Step 2 Go to IV dextrose infusion step 1, and proceed from there

D12.5%W, 4 to 5 mL/kg/hour (8.3 to 10.4 mg/kg/minute of glucose)

Obtain consultation and investigations

Consider central access if on > D12.5%W

Consider glucagon or other pharmacological intervention if > D12.5%W is needed


The Thermoregulation Sequence


The Infection Sequence


Notes re Infection Sequence

A well term baby born to an asymptomatic mother with a negative prenatal GBS screen or > 4 hours of intrapartum antibiotics, does not need specific intervention. Such a baby has no Alerting Signs for infection, and does not enter the Infection Sequence

A baby who has ACoRN alerting signs with * should have diagnostic testing for sepsis and antibiotic therapy; except term and late preterm babies with mild respiratory distress lasting < 4 hours who are otherwise well and have no risk factors for infection.

First-line antibiotics in sepsis occurring in the first 3 days of life are ampicillin and an aminoglycoside (usually gentamicin). If meningitis cannot be ruled out in an unwell baby, cefotaxime should be added.

Notes re Transport

The sending facility needs to prepare the following material to go with the baby:

a copy of o prenatal, labour and delivery records o the mother’s chart with all relevant neonatal history o the baby’s chart o laboratory data

radiographs o note on the last chest radiograph if the endotracheal tube has been repositioned and no new

radiographs have been taken

clearly labeled specimens if requested, for example o the baby’s blood cultures (aerobic ± anaerobic) o a maternal blood sample o a cord blood sample from the placenta, useful mainly for a direct antibody (Coombs’) test

the placenta, wrapped in a sealed plastic bag or placed in a bucket with a lid (no additives or preservatives)

signed consent forms for transport, admission and care at the receiving hospital, and for transfusion of blood products

contact information for the baby’s parents and family physician.


Transport Neonatal Pre-Transport Communication Sheet

Date & time: Physician calling: Phone

Institution calling: City Phone

Institution accepting: City Phone

Information about the newborn

Name: Reason for consultation:

Date of birth Time Sex Birth weight Gestation Apgar score Eye prophylaxis? 1 min: 5 min: Vitamin K? Resuscitation: Congenital anomalies:

Respiration Cardiac massage Medications / route

Spontaneous: Yes ( ) No ( ) Manual ventilation: Yes( ) No ( ) Oxygen: Yes ( ) % No ( )

Intubated: Time ETT size ______ Suctioned for meconium: Yes ( ) No ( )

Yes ( ) No ( )

Time: Started: ____

Ended: ________

ET/EV ET/EV ET/EV ET/EV

Cord gases:

Postnatal course: Curent condition:

HR: RR: BP: Capillary refill: sec FiO2: IPPV: SpO2: Physical exam:

IV access / solutions Medications / route: RX – results Blood glucose (time) Blood gases (time)

Information about the mother:

Name: Age: G: P: LMP / EDC /

Blood group: Rh: VDRL: Rubella: HBsAG: TB: HIV:

GBS: Pos ( ) Neg ( ) Unknown ( ) Other

Focused history:

Labor / birth:

Fetal monitoring: Yes ( ) No ( ) Internal ( ) External ( ) Auscultation ( ) Normal ( ) Abnormal ( )

Scalp blood gases Duration: 1st stage 2d stage SROM ( ) AROM ( ) Duration: Color: AFV: Medications: Analgesia /anesthesia:

Birth: Cesarean ( ) Vaginal ( ) Forceps ( ) Vacuum ( ) Presentation:

Complications:

Date: Name & position:

Adapted: PPPESO. Neonatal Transport. Perinatal Nursing Guidelines (3rd Ed). Ottawa, ON: Perinatal Partnership Program of Eastern and Southeastern Ontario, 2001.

Documents

ACoRN Workbook “2012 Update” · ACoRN Workbook “2012 Update” _____ Name: ACoRN Neonatal Society ... SpO 2 Degree of desaturation Stable Circulatory instability or anemia >