ICU AND YOU · Superquiz #60

1A 29-week infant is delivered. Which approach best prevents heat loss in the delivery room?

ADry thoroughly, then place under a radiant warmer with a hat BWarm blankets and a hat, with handling kept to a minimum CDelay all thermal measures until the infant reaches the incubator DPlace directly into polyethylene wrap without drying the body, plus a thermal mattress, hat and radiant warmer

Below 32 weeks the infant goes straight into polyethylene wrap without being dried, on a thermal mattress, with a hat and under a radiant warmer. Drying first wastes the very minutes you are trying to protect. Target axillary temperature is 36.5–37.5 °C, and the room should be at 23–25 °C with the doors shut. Watch for hyperthermia too — the combination of mattress and wrap can overshoot.

ANZCOR Guideline 13.4; and see the mind map for this topic, first station.

2A term newborn is apnoeic. You have given positive pressure ventilation for 30 seconds. The heart rate is 50 and the chest is not moving. Your next step is:

ABegin chest compressions at 3:1 BGive adrenaline 10–30 µg/kg via the umbilical vein CWork through the corrective ventilation steps DIncrease the oxygen to 100% and continue as you are

A chest that is not moving means the lungs are not being inflated, and nothing downstream will work until they are. MR SOPA: Mask seal, Reposition the airway, Suction, Open the mouth, Pressure up, Airway alternative. Compressions are indicated only once ventilation is effective and the rate remains below 60 — starting them now simply interrupts the one intervention that could help.

ANZCOR Guideline 13.5, Ventilation of the Newborn.

3A two-hour-old term infant of a diabetic mother is jittery. Blood glucose is 1.6 mmol/L. The most appropriate immediate management is:

AIntravenous 10% dextrose 2 mL/kg, then an infusion BFeed and recheck the glucose in one hour CAwait a laboratory glucose before acting DIntramuscular glucagon

Symptomatic hypoglycaemia is treated intravenously, not enterally: 2 mL/kg of 10% dextrose — about 200 mg/kg — followed by an infusion, then recheck within thirty minutes. Feeding alone is reasonable for an asymptomatic baby in the higher ranges, but not for a jittery infant at 1.6. Send the confirmatory laboratory sample by all means, and do not wait for it. Consider critical samples if hypoglycaemia persists.

AAP screening and management of postnatal glucose homeostasis; confirm thresholds against your local protocol.

4Which combination is required before starting therapeutic hypothermia for hypoxic-ischaemic encephalopathy?

AAny gestation, started within 12 hours, cooled to 30–32 °C B35 weeks or more, started within 6 hours of birth, cooled to 33–34 °C C37 weeks or more, started within 24 hours, cooled to 35 °C DMRI confirmation of injury before cooling begins

Moderate to severe encephalopathy at 35 weeks or more, begun within six hours of birth, to a core temperature of 33–34 °C for 72 hours, then rewarmed slowly. The window is short and it does not reopen, which is why the decision has to be made on clinical grounds — telephone the retrieval service before you are certain, because passive cooling begins with turning the warmer off and that cannot be done retrospectively.

Jacobs SE et al. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev 2013;(1):CD003311.

5A three-day-old, previously feeding well, has two episodes of green vomiting. The abdomen is soft and the infant otherwise looks well. The most important immediate concern is:

APhysiological reflux BLate-onset sepsis CMalrotation with volvulus DOverfeeding

Bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise, and a soft abdomen in a well-looking baby is exactly how it presents before the bowel infarcts. This is a surgical emergency measured in hours: urgent upper gastrointestinal contrast study and paediatric surgical referral. Sepsis and reflux are on the list, but neither justifies waiting.

Laje P. Abdominal Surgical Emergencies in Neonates. Neoreviews 2023;24(2):e97–e106.

Neonatology

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