ACoRN Workbook “2010 Update”

ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society

ACoRN Workbook

“2010 Update”

_____________________________________ Name:

ACoRN Neonatal Society Société néonatale “ACoRN”

A Canadian non-profit Society Vancouver, British Columbia

www.acornprogram.net

The ACoRN Process


ACoRN Acute Care of at-Risk Newborns

The ACoRN Editorial Board Chair: Alfonso Solimano, MD, FRCPC

British Columbia: Alfonso Solimano, MD, FRCPC Emily Ling, MD, FRCPC Debra O’Flaherty, RN, BScN, MSN Lynn Beaton, RRT

Alberta: Nalini Singhal, MD, FRCPC Manitoba: Judith Littleford, MD, FRCPC

Ontario: Jill Boulton, MD, FRCPC Ann Mitchell RN, BNSc, MEd Brian Simmons, MB, FRCPC David Price, BSc, MD, CCFP

Newfoundland

and Labrador:

Khalid Aziz, MBBS, FRCPC

Editorial Direction and Project Leadership

Alfonso Solimano, MD, FRCPC Judith Littleford, MD, FRCPC Emily Ling, MD, FRCPC Debra O’Flaherty, RN, BScN, MSN

Managing Editors

(first and second revised printing)

Alfonso Solimano, MD, FRCPC Emily Ling, MD, FRCPC Debra O’Flaherty, RN, BScN, MSN

Managing Editors

(updated third printing, ‘2010 version’)

Alfonso Solimano, MD, FRCPC Debra O’Flaherty, RN, BScN, MSN Horacio Osiovich, MD, FRCPC Elene Vanderpas, RN, BScN

The ACoRN Process


The ACoRN Process

The ACoRN Process


The Resuscitation Sequence

The ACoRN Process


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- 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 ACoRN Process


The Respiratory Score (p. 3-7): Score 0 1 2

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

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

Acceptable values for newborns with acute respiratory distress (p. 3-42, D-3): pH 7.25 to 7.40

PCO2 45 to 55 mmHg

BD - 4 to + 4 mmol/L

SpO2 88 to 95%

The ACoRN Process


The Cardiovascular Sequence

The ACoRN Process


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 Tolerance

> 75% mild to moderate usually well tolerated

65 to 75% marked may be less well tolerated if baby otherwise sick

< 65% severe 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 ACoRN Process


The Neurology Sequence

The ACoRN Process


Clinical assessment of severity in HIE (p. 5-25): Mild Moderate Severe

Alertness “hyperalertness” lethargy stupor/coma

Tone normal/increased decreased flaccid

Tendon reflex increased increased depressed

Moro exaggerated incomplete absent

Seizures absent present difficult to control

Breathing regular variable apnea

Suck reflex present weak absent

Gag reflex present present absent

Adaptado de Sarnat HB et al: Neonatal encephalopathy following fetal distress: A clinical and encephalographic study. Arch Neurol 33:695,1976 Documentation of abnormal movements (p. 5-29):

Time/ duration

Suppress by holding

Origin/ spread

Eye/mouth movements

Level of alertness

Autonomic changes

Other signs

09:00 h 20 sec

No Arm, then all extremities

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

No No

Management of temperature in newborns with HIE (p. 5-17): In babies with moderate to severe HIE it is important to initiate consultation and to consider transport to the regional referral center as soon as possible.

Hyperthermia must be avoided as it increases the risk and severity of neurodevelopmental morbidities.

Mild therapeutic hypothermia expertly administered and initiated within the first 6 hours of life in babies ≥ 35 weeks gestation with moderate to severe hypoxic ischemic encephalopathy decreases mortality and the severity of neurodevelopmental morbidities.

The ACoRN Process


The Surgical Conditions Sequence

The ACoRN Process


The Fluid & Glucose Management Sequence

The ACoRN Process


Guide for enteral and intravenous fluid administration (p. 7-4): Postnatal age Baseline oral 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

The ACoRN Process


The Thermoregulation Sequence

The ACoRN Process


The Infection Sequence

The ACoRN Process


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

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

Spontaneous: Yes ( ) No ( ) Manual ventilation: Yes( ) No ( ) Oxygen: Yes ( ) % No ( ) Intubated: Time ETT size ______ Suctioned for meconium: Yes ( ) No ( )

Yes ( ) No ( )

Time: Started: ____ Ended: ________ Cord

gases:

Postnatal course:

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

Curent condition:

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: Rubeola: 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:

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

Documents

ACoRN Workbook “2010 Update”