Post on 19-Mar-2022
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 Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The ACoRN Process
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Resuscitation Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Cardiovascular Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Neurology Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Surgical Conditions Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Fluid & Glucose Management Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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
Day 2 (96 mL/kg/day)
up to 8 mL/kg q 2h (12 mL/kg q 3h)
D10%W at 4 mL/kg/hour
Day 3 (120 mL/kg/day)
up to 10 mL/kg q 2h (15 mL/kg q 3h)
D10%W with 20 mmol/L of NaCl at 5 mL/kg/hour
≥ Day 4 (144 mL/kg/day)
up to 12 mL/kg q 2h (18 mL/kg q 3h)
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
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Thermoregulation Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
The Infection Sequence
The ACoRN Process
ACoRN Workbook v 1.3.00 – 19/10 (2010 Update) © ACoRN Neonatal Society
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.