Neonatal Intensive Care : Principles and Guidelines

The significant strides made during the past decade in neonatal medicine are based largely upon the provision of intensive perinatal care to the parturient, her fetus, and the newborn. In addition to technologic advances in the bioelec­ tronic monitoring of the fetus and newborn, the introduction of noninvasive methods to monitor oxygenation, the pharma­ cologic manipulation ofthe ductus arteriosus and pulmonary vasculature, and the use of ultrasonographic diagnosis of congenital heart defects and other lesions, intensive efforts by neonatal specialists throughout the world have also contri­ buted to the decline in neonatal and infant mortality. Professors Wille and Obladen have provided an authoritative manual outlining intensive care of newborns and the ways in which the science of neonatal medicine, the technology of the 1980 s, and the art of application have resulted in the practice of neonatal intensive care at the Kinderklinik of the University of Heidelberg. The English translation resulted from the success of the German edition and will serve well the needs of the English-speaking student and practitioner of neonatal intensive care. T. Allen Merrit, M. D.

1. Practical Management of High-Risk Newborns.- Evaluation and Treatment of the Newborn Immediately After Birth.- 1.1 Predisposing Risk Factors.- 1.2 Diagnosis of Postpartum Condition.- 1.3 Classification of Asphyxia.- 1.4 Primary Care and Resuscitation.- 1.5 Assessment of Gestational Age.- 1.5.1 Definitions.- 1.5.2 Requirements for Assessment of Gestational Age.- 1.5.3 Criteria for Assessment of Gestational Age.- 1.6 Intrauterine Growth Curves.- 1.7 Differentiation Between Preterm and Small-for-Gestational-Age Infants.- 1.8 Determining the Stage of Dysmaturity.- 1.9 Main Symptoms During the First Days of Life.- 1.1 References.- 2 Transport of High-Risk Newborns.- 2.1 Indications for Transfer.- 2.2 Informations Prior to Transport.- 2.3 Organization and Conduct of the Transport.- 2.4 Equipment of a Mobile Intensive Care Unit.- 2.5 Contents of the Emergency Kit.- 2.6 Measures Following Transport.- 2.2 References.- 3 Patient Supervision.- 3.1 Pulse and Heart Rate.- 3.2 Variance of the Heart Rate.- 3.3 Respiration.- 3.4 Temperature.- 3.4.1 Servocontrol.- 3.4.2 Temperature Monitoring.- 3.4.3 Intermittent Manual Measurement.- 3.4.4 Incubator Temperature.- 3.5 Blood Pressure.- 3.5.1 Flush Method.- 3.5.2 Detection of Pulse Waves or Vascular Movements with Ultrasound.- 3.5.3 Direct Measurement.- 3.6 Central Venous Pressure.- 3.6.1 Umbilical Vein Catheter.- 3.6.2 Continuous Measurement with Electronic Pressure Transducer.- 3.7 Computer-Assisted Patient Monitoring.- 3.3 References.- 4 Nutrition During the First Days of Life.- 4.1 General.- 4.2 Oral Feeding.- 4.2.1 Healthy Term Infants.- 4.2.2 Preterm Infants.- 4.2.3 Small-for-Gestational-Age Infants.- 4.2.4 Sick Infants.- 4.3 Nasojejunal Feeding.- 4.4 Supplementary Intravenous Feeding.- 4.5 Total Parenteral Nutrition.- 4.4 References.- II. Diagnosis and Treatment of Respiratory Disorders.- 5 Blood Gas Analysis.- 5.1 Measuring Techniques.- 5.1.1 Direct Measurement with Sensitive Electrodes (e. g., Corning, AVL).- 5.1.2 Indirect Measurement.- 5.1.3 Criteria for Selecting a Blood Gas Analyzer.- 5.2 Transcutaneous Oxygen Measurement.- 5.3 Collection of Blood Samples.- 5.3.1 Capillary Sampling.- 5.3.2 Warmed Capillary Sampling.- 5.3.3 Arterial Puncture.- 5.3.4 Umbilical Artery Catheter.- 5.3.5 Indwelling Catheter in Radial or Temporal Artery.- 5.4 Interpretation.- 5.5 Blood Gas Analysis: Normal Values in the Newborn.- 5.6 Disturbances of the Acid-Base Balance.- 5.7 Medicinal Treatment of Acid-Base Disturbances.- 5.7.1 Indications.- 5.7.2 Dosage.- 5.7.3 Administration.- References.- 6 Oxygen Therapy.- 6.1 Indication.- 6.2 Hypoxia Diagnosis, Hyperoxia Test.- 6.2.1 Indication for Artificial Ventilation.- 6.2.2 Differential Diagnosis of Congenital Heart Defects.- 6.3 Oxygen Dissociation.- 6.4 Causes of Disturbances in Oxygenation.- 6.4.1 Impaired Ventilation.- 6.4.2 Impaired Diffusion.- 6.4.3 Impaired Perfusion.- 6.4.4 Disturbances of Oxygen Binding and Oxygen Transport.- 6.5 Dosage of Oxygen in Respiratory Gas.- 6.5.1 PaO2 Measurement.- 6.5.2 tcPO2 Measurement.- 6.6 Modes of Administration.- 6.6.1 Incubator.- 6.6.2 Plastic Head Box (Oxyhood).- 6.6.3 Ventilation.- 6.7 Side Effects of Oxygen Therapy.- 6.7.1 Retrolental Fibroplasia.- 6.7.2 Bronchopulmonary Dysplasia.- 6.7.3 Ventilatory Depression.- References.- 7 Artificial Ventilation M. Obladen.- 7.1 Ventilatory Status of the Newborn.- 7.2 Indication for Artificial Ventilation.- 7.2.1 Birth Asphyxia or Emergency.- 7.2.2 Central Respiratory Disturbance and Immaturity.- 7.2.3 Respiratory Distress Syndrome.- 7.2.4 Aspiration Syndrome.- 7.2.5 Cardiac Failure.- 7.3 Technical Essentials.- 7.3.1 Disinfection of Tubing and Equipment.- 7.3.2 Assembly of Ventilator Tubing.- 7.4 Ventilators and Their Operation.- 7.4.1 Classification of Some Ventilators Suitable for Neonatal Use.- 7.4.2 Bird Mark.- 7.4.3 Bourns LS 104–150.- 7.4.4 Bourns BP 200.- 7.4.5 Cavitron PV 10, Biomed MVP 10.- 7.4.6 Ventilator Test Run.- 7.4.7 Basic Settings of a Neonatal Ventilator Ready for Use.- 7.4.8 Intermittent Mandatory Ventilation (IMV).- 7.5 Continuous Positive Airway Pressure (CPAP).- 7.5.1 Definitions.- 7.5.2 Principle.- 7.5.3 CPAP System.- 7.5.4 CNP System (Pulmarca).- 7.5.5 Comparison of CNP and CPAP.- 7.5.6 Complications and Side Effects of CPAP.- 7.6 Control of Ventilation.- 7.6.1 Control Scheme.- 7.6.2 Changing the Ventilator Settings.- 7.7 Examples of Ventilation.- 7.7.1 Immature Preterm Infant with Apneic Attacks and Central Respiratory Disturbance.- 7.7.2 Preterm Infant, Stage-II RDS, Stabilization by Prolonged Inspiration.- 7.7.3 Preterm Infant, Stage-III RDS, Weaning by Use of IMV.- 7.7.4 Child of Diabetic Mother, Stage-IV RDS, Stabilization by High Inspiratory Pressure.- 7.7.5 Heart Defect with Iatrogenic Hyperventilation.- 7.7.6 Meconium Aspiration with Severe Respiratory Failure.- 7.8 Recognition of Equipment Malfunctions.- 7.8.1 Principle.- 7.8.2 Pressure-Controlled Ventilation.- 7.8.3 Volume-Controlled Ventilation with Prolonged Inspiration, High Volume, and Pressure Limit.- 7.8.4 CPAP and PEEP.- References.- 8 Long-Term Ventilation.- 8.1 General Requirements.- 8.1.1 Prevention of Infection.- 8.1.2 Suctioning.- 8.1.3 Humidification and Nebulization.- 8.1.4 Heating.- 8.1.5 Physiotherapy.- 8.1.6 Postural Therapy.- 8.1.7 Feeding.- 8.2 Supervision of the Neonate During Artificial Ventilation.- 8.2.1 Observation and Examination of the Artificially Ventilated Neonate.- 8.2.2 Supervision by Monitor.- 8.2.3 Monitoring the Ventilator Settings.- 8.3 Relaxation.- 8.3.1 Indication for Relaxation.- 8.3.2 Dosage and Procedure.- 8.4 Concluding Artificial Ventilation.- 8.4.1 Weaning from the Ventilator.- 8.4.2 Procedure of Weaning.- 8.4.3 Extubation.- 8.4.4 Procedure of Extubation.- 8.5 Complications.- 8.5.1 Blockage of Endotracheal Tube.- 8.5.2 Tube Dislocation.- 8.5.3 Accidental Disconnection.- 8.5.4 Infection.- 8.5.5 Extra-Alveolar Collection of Air.- 8.5.6 Disturbances of Venous Return.- 8.5.7 Patent Ductus Arteriosus.- 8.5.8 Inappropriate Secretion of ADH.- 8.6 Delayed Damage After Long-Term Ventilation.- 8.6.1 Pressure Lesions.- 8.6.2 Bronchopulmonary Dysplasia.- References.- III. Acute Neonatal Diseases.- 9 Pulmonary Diseases.- 9.1 Respiratory Distress Syndrome (Surfactant Deficiency).- 9.2 Aspiration Syndrome.- 9.3 Pneumothorax.- 9.4 Acute Pulmonary Hemorrhage.- References.- 10 Cardiological Problems in the Newborn.- 10.1 The Newborn with Congenital Heart Disease.- 10.1.1 Differential Diagnosis of Congenital Heart Disease in the Newborn.- 10.1.2 General and Special Cardiological Diagnostic Tests in Suspected Neonatal Heart Disease.- 10.1.3 Cardiac Surgery in the Newborn.- 10.2 Urgent Cardiac Diagnosis in the Newborn.- 10.2.1 Transposition of the Great Arteries (TGA).- 10.2.2 Coarctation of the Aorta (COA).- 10.2.3 Hypoplastic Left Heart Syndrome (HLHS).- 10.2.4 Primary Myocardial Disease.- 10.3 Cardiological Emergencies in the Newborn.- 10.3.1 Congestive Heart Failure.- 10.3.2 Cardiac Arrhythmias.- 10.3.3 Patent Ductus Arteriosus in Premature Infants with Respiratory Distress Syndrome.- 10.3.4 Persistent Fetal Circulation Syndrome.- 10.3.5 Pneumopericardium.- References.- Neurologic Diseases.- 11.1 Postasphyxia Syndrome.- 11.2 Neonatal Seizures.- 11.3 Recurrent Apneic Spells.- 11.4 Intracranial Hemorrhage.- 11.4.1 Subdural Hemorrhage.- 11.4.2 Primary Subarachnoid Hemorrhage.- 11.4.3 Periventricular Intracerebral (Intraventricular) Hemorrhage.- References.- 12 Acute Abdominal Diseases.- 12.1 Acute Gastrointestinal Diseases.- 12.2 Necrotizing Enterocolitis.- 12.3 Acute Renal Failure.- References.- Disorders of Metabolism.- 13.1 Hypoglycemia.- 13.2 Infants of Diabetic Mothers.- 13.3 Hyperglycemia.- 13.4 Acute Metabolic Disorders.- References.- 14 Disturbances of the Electrolyte Balance.- 14.1 Hyponatremia 150 mEq/l.- 14.3 Hypokalemia < 3.8 mEq/l.- 14.4 Hyperkalemia > 7 mEq/l.- 14.5 Hypocalcemia.- 14.6 Hypomagnesemia < 1,2 mEq/l.- References.- 15 Icterus Gravis Neonatorum and Hemolytic Disease of the Newborn (L. Wille).- 15.1 Definitions.- 15.2 Differential Diagnosis and Diagnostic Procedure for Neonatal Jaundice.- 15.3 Hemolytic Disease of the Newborn.- 15.3.1 Rh Erythroblastosis (Anti-D).- 15.3.2 Hemolytic Disease Due to Rare Sensitizations to Blood Group Factors Other than A, B, D (Anti-C, -c, -E, -e, Anti-Kell, -Duffy).- 15.3.3 ABO Erythroblastosis.- 15.4 Hemolytic Diseases Without Isoimmunization.- 15.5 Hyperbilirubinemia Without Hemolysis.- 15.5.1 Term Infants.- 15.5.2 Preterm Infants.- 15.6 Hyperbilirubinemia in Hepatocellular or Obstructive Jaundice.- 15.7 Technique of Exchange Transfusion.- 15.8 Phototherapy.- 15.9 Hydrops Fetalis.- References.- 16 Infections.- 16.1 Prevention of Bacterial Infections.- 16.2 Bacteriologic Diagnosis.- 16.3 Sepsis.- 16.4 Meningitis.- 16.5 Intrauterine Infections.- References.- 17 Hematologic Disease.- 17.1 Anemia.- 17.2 Hypovolemic Shock.- 17.3 Polycythemia.- References.- 18 Blood Coagulation and Hemorrhagic Diatheses.- 18.1 Blood Coagulation.- 18.2 Diagnosis.- 18.3 Coagulopathies.- 18.3.1 Congenital Coagulopathies.- 18.3.2 Acquired Coagulopathies.- 18.4 Thrombocytopenia.- 18.5 Thrombocytopathy.- References.- IV. Appendix.- 19 Techniques of Neonatal Intensive Care.- 19.1 Umbilical Vessel Catheterization.- 19.1.1 Umbilical Vein Catheterization.- 19.1.2 Umbilical Artery Catheterization.- 19.2 Technique of Superior Vena Cava Catheterization.- 19.3 Arterial Puncture and Catheterization.- 19.3.1 Puncture of the Radial and Brachial Arteries.- 19.3.2 Percutaneous Catheterization of the Radial Artery.- 19.3.3 Percutaneous Catheterization of the Temporal Artery.- 19.4 Venesection.- 19.5 Drainage of Pneumothorax.- 19.5.1 Exploratory Puncture.- 19.5.2 Technique of Pleural Drainage.- 19.6 Drainage of Pneumopericardium.- 19.7 Abdominal Paracentesis.- 19.8 Endotracheal Intubation.- 19.8.1 Orotracheal Intubation.- 19.8.2 Nasotracheal Intubation.- 19.8.3 Confirmation of Tube Placement.- 19.8.4 Tube Lengths.- 19.8.5 Fixation of Tube.- 19.8.6 Most Frequent Sources of Error During Intubation.- 19.9 Technique of Peritoneal Dialysis.- 19.10 Ventriculopuncture.- References.- 20 Instrumentarium for Procedures in Neonatal Intensive Medicine.- 20.1 Intubation Set.- 20.2 Pneumothorax Set.- 20.3 Abdominal Paracentesis Set.- 20.4 Umbilical Catheter Set.- 20.5 Venesection Set.- 20.6 Peritoneal Dialysis Set.- 21 Neonatal Drug Therapy (L. Wille).- References.- Results of Neonatal Intensive Care.- 22.1 Neonatal Mortality.- 22.1.1 Organizational Measures for Reducing Neonatal Mortality.- 22.2 Cerebral Handicaps.- 22.2.1 Incidence.- 22.2.2 Prognostic Value of Neonatal Risk Factors.- 22.2.3 Origin of Perinatal Brain Damage.- 22.3 Follow-Up Examination.- 22.3.1 Timing.- 22.3.2 Examination Procedure.- 22.4 Economic Aspects.- References.- 23 Parents in the Intensive Care Unit.- 23.1 Normal Reaction of Parents to the Birth of a Premature or Sick Infant.- 23.2 Consequences of Prolonged Maternal-Infant Separation.- 23.3 Parental Functions in the Intensive Care Unit.- 23.4 Informing the Parents.- 23.5 Conference Following the Death of a Newborn.- 23.6 Atmosphere of the Intensive Care Unit.- References.- 24 Subject Index.