9/15/2019 Pgi Nicu Handbook Of Protocols
AIIMS protocols in Neonatology 2014, CBS Publishers, Delhi All good neonatal units follow protocol-based management of sick neonates for uniform standard clinical care. Consenting to follow the agreed protocols serves as a catalyst for new ideas to improve clinical care. These protocols however must be viewed as generic in nature. Suitable adaptation may be done at individual centers through the process of consultation with other team members.
As new evidence emerges, and ones own experience becomes richer, the protocols will need to be updated and revised. Our unit at AIIMS published a series of protocols in IJP in the year 2003, 2008; these protocols have been revised and modified in the light of current emerging evidences and changing practices in our unit and published for wide spread dissemination by CBS Publishers, New Delhi. With use of antenatal steroids and early use of CPAP, the babies needing invasive ventilation has declined. Similarly with better monitoring of oxygen therapy, rational use of blood transfusion and improved supportive care, over the last decade the number of babies needing intervention for retinopathy of prematurity has gradually decline.
This happened as nurses and physicians followed standard protocols laid in house for management of sick babies. We are sure many of you who would adhere to these evidence based guidelines will notice better outcomes in survivals on follow up. The editors are grateful to all those who have contributed for compilation of these evidence based protocols. One can access the protocols on our website www.newbornwhocc.org.
We would welcome suggestions and comments, if any, which will improve quality of care of sick neonates in resource poor developing countries. Dr Ramesh Agarwal, Prof. Deorari & Prof.
Paul Division of Neonatology Department of Pediatrics All India Institute of Medical Sciences Ansari Nagar, New Delhi - 110 029.
Fluidelectrolytesbablance150308.pdf - AIIMS- NICU protocols 2008 Fluid and electrolyte management in term and preterm neonates Deepak Chawla, Ramesh Agarwal, Ashok Deorari, Vinod K Paul Download our pgi nicu handbook of protocols blue books eBooks for free and learn more about pgi nicu handbook of protocols blue books. These books contain exercises and tutorials to improve your practical skills, at all levels!
This manual, now in its eighth edition, is designed for use by the pediatric residents, interns and medical students who work in the at UCSF Benioff Children's Hospital. The recommendations in this manual are specific for the practices in that unit.
If this manual is used in other intensive care nurseries, it must be revised and adapted to suit the circumstances in those units. This is not a mini-textbook or outline of neonatology. The purpose of this manual is to assist pediatric house officers by providing:. Guidelines for the management of patients with conditions that require immediate attention. Reminders to help them in their daily work. Detailed instructions for performing procedures There is little discussion of pathophysiology, which is covered in textbooks.
Certain important and common problems are not covered at all. This particularly applies to most chronic problems, as they can be discussed on attending rounds.
Section I: Procedures.:. Catheterization of Umbilical Vessels. Peripheral Arterial Catheterization. Percutaneous Venous Catheterization. Section II: General Care. Section III: Specific Conditions Pulmonary. Cardiovascular.
Hematologic. Infectious Diseases. Gastrointestinal. Neurological. Metabolic.
Surgical Patients. Other. The documents on this page are in Portable Document Format (PDF). They can be viewed using Adobe Acrobat Reader. If you do not have Adobe Acrobat Reader, you can download it for free from Adobe's Web site.
Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity.
As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices.
The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.
Neonatal hyperbilirubinaemia is a leading cause of hospital admission/re-hospitalisation in the first week of life globally -. Timely and appropriate treatment with phototherapy and/or exchange transfusion are effective in controlling excessive bilirubin levels in the affected infants ,. Otherwise, severe hyperbilirubinaemia may progress to acute bilirubin encephalopathy (ABE) or kernicterus with a significant risk of mortality in newborns -. Survivors may also acquire long-term neurodevelopmental sequelae such as cerebral palsy, sensorineural hearing loss, intellectual difficulties or gross developmental delays -. It is estimated that, worldwide, severe hyperbilirubinaemia affects at least 481,000 term or near-term newborn babies annually, of whom 114,000 die and more than 63,000 survive with moderate or severe disability ,. At least, 75% of the affected infants reside in sub-Saharan Africa and South Asia.
In low- and middle-income countries (LMICs), delay in seeking care for infants with hyperbilirubinaemia as well as delay in providing appropriate treatment when affected infants present in health facilities is commonly reported ,. Where phototherapy devices are available, if at all, lack of relevant guidelines or inadequate knowledge of essential requirements for effective treatment results in frequent and potentially avoidable exchange transfusions -. We, therefore, set out to identify key considerations for the effective management of late-preterm and term infants (≥35 weeks of gestation) with significant hyperbilirubinaemia presenting at health facilities in LMICs. Guidelines for the management of hyperbilirubinaemia in high-income countries are unlikely to address the peculiar challenges in LMICs without appropriate modification ,. Adaptation of existing evidence-based guidelines from one geographical, economic and socio-cultural context to another is an internationally accepted alternative to the more costly, time-consuming, de novo guideline development for improved health care delivery. In this report, we followed relevant protocols of the WHO Handbook for Guideline Development , ADAPTE Guideline Adaptation Toolkit , and AGREE II-Global Rating Scale , for the adaptation of clinical practice guidelines.
Based on prior in-depth reviews of the literature from 1970 to 2013 on the burden of neonatal hyperbilirubinaemia and current management practices in LMICs , , we identified four major themes for improving the care of affected infants namely: primary prevention, early detection and monitoring, treatment and follow-up. We then undertook a review of existing guidelines (see Additional file: Table S1) and relevant literature from both high-income and LMICs to identify key issues relevant to improved care at primary, secondary and tertiary levels in LMICs ,. The existing guidelines were rated individually by the core working group (CWG) and one external content methodologist who had no prior involvement with generating these guidelines. The overall average score for each guideline was computed based on the seven components of the AGREE-II instrument: methodology, presentation, completeness, appropriateness, overall quality, disposition for personal use and likelihood of recommending the guideline to others. We developed a practice framework for different levels of newborn care based on essential tools and skills considered appropriate for each level of care.
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The proposals aimed at balancing the safe, effective, patient-centred, timely, efficient and equitable components of quality care enunciated by the Institute of Medicine , as well as minimising the risk of unintended harms such as costly, unnecessary overtreatment or increased parental anxiety. Where scientific evidence was lacking or limited, proposed actions were based on consensus among the CWG using the Delphi process. The draft and final proposals were critically reviewed by an international panel of experts for scientific soundness and practicality.
The experts were identified and agreed by the CWG based on their independently verifiable work on the subject-matter and with a view to achieving a fair representation from all world regions. While the expert panel review was not intended as individual endorsement of the entire framework, all comments and queries were carefully addressed by the CWG in subsequent revisions. Authors made reasoned judgment where contradictory views were expressed by panel members on an issue -. For clarity and consistency the key terminologies and definitions used in this report are summarised in Table (also Additional file ). Terminology Definitions Clinically significant hyperbilirubinaemia Significant hyperbilirubinaemia: any unconjugated bilirubin level requiring treatment with phototherapy which varies with post-natal age and aetiology (typically TSB ≥12 mg/dL (205 μmol/L) in many LMICs).
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Severe hyperbilirubinaemia: Bilirubin levels at/near exchange transfusion levels based on post-natal age and aetiology (typically TSB ≥20 mg/dL or 342 μmol/L in many LMICs) and/or any elevated TSB associated with signs of acute bilirubin encephalopathy. Bilirubin encephalopathy: abnormal neurological signs and symptoms caused by bilirubin toxicity to the basal ganglia and various brainstem nuclei.
Acute bilirubin encephalopathy (ABE): acute manifestations of bilirubin toxicity seen within fourteen days after birth. Classic early signs include poor feeding, lethargy and tone abnormalities progressing to high-pitched cry, increasing hypertonia - especially of extensor muscles, with retrocollis, opisthotonus and obtundation in association with the kernicteric facies. Kernicterus: Permanent or chronic neurologic damage, including choreo-athetoid cerebral palsy, enamel dysplasia, paralysis of upward gaze, hearing impairments including auditory neuropathy spectrum disorders.
Low- and middle-income countries (LMICs) The target population for this review consists of the 91 countries with per capita Gross National Income (GNI) of ≤ US$6,000 using the Human Development Report 2013 by the United Nations Development Program (UNDP) as there is no single definition of “resource-poor countries” in the literature and developmental status varies greatly among the approximately 140 countries classified as LMICs by the World Bank. (see Additional file: Table S2) Levels of health care delivery Three levels of healthcare delivery were considered: primary, secondary and tertiary.
Typically, the primary level consists of community health centres and outposts managed by community health workers. Secondary/first-level referral centres include district or general hospitals while the tertiary level consists of specialist or teaching hospitals.
Levels of intervention and required facilities for severe jaundice. The average AGREE II-GRS ratings of the 21 guidelines reviewed ranged from 41% for Ghana and 99% for UK’s NICE (see Additional file: Table S1). Priority was given to guidelines with high quality scores (≥70%) except for issues pertinent to clinical practice in LMICs but not explicitly addressed by these guidelines such as factors accounting for delays in seeking and receiving appropriate care.
Only four guidelines (Ghana, India, Kenya and WHO) were from eligible LMICs, and two (Ghana and WHO) did not meet the 70% quality rating threshold. The American Academy of Paediatrics (AAP) guideline was the benchmark for the majority of high scoring national guidelines including NICE ,.
The interventions and tools proposed for each level of health care delivery are summarised in Table. Proposed tasks or tests Applicable level of care. Suggested tools and facilities Primary prevention. Education of existing and expectant mothers, families and health care providers on P, S & T:. Educational materials including posters and audio-visual aids where available, pictures and/or video clips of infant survivors of BIND and/or Kernicterus. My dear bootham sun tv serial wiki.
This material should include signs of both early and late ABE/BIND and potential long-term consequences of ABE/BIND for both the community and the health care providers. P, S & T o The transient physiologic course but with potential to increase to harmful levels and it's variability from baby to baby o The avoidance of haemolytic substances (including camphor/naphthalene balls, menthol-containing powder, creams and balms, e.g. Wintergreen oil). O The benefits of early detection accompanied by timely and appropriate treatment in health facilities adequately-equipped for newborn care. Access to laboratory appropriately resourced for clinical investigations. S & T o Discouraging traditional therapies as well as indiscriminate use of self-prescribed medications e.g.
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O Recognition of acute bilirubin encephalopathy/Bilirubin-Induced Neurologic Dysfunction (BIND) o The value of “clean birth” to prevent or minimize the risk of infection (sepsis). Referral to secondary or tertiary centers of all preterm babies (20 mg/dL. Jordin sparks battlefield album zip. S & T. Consider Magnetic Resonance Imaging (MRI) for early detection of potential neurotoxicity if readily available, can be done without sedation and does not delay treatment.
T. Disseminate information on the local providers of age-appropriate developmental evaluation of infants and young children to the affected parents on discharge or during any subsequent clinical consultations.Level of care where task/test should be available routinely: Primary/Community Health Center P, Secondary/District Hospital S, Tertiary/Children’s’ Hospital T. For a comprehensive list of essential infrastructural and human resources typically required for secondary/district hospitals see: UNICEF India.
Toolkit for Setting up of Special Care Units, Stabilization Units and Newborn Care Units. New Delhi: UNICEF India, 2009. ➢ → Conventional Phototherapy (CPT): Phototherapy in which intensity of blue light (400–520 nm) with a peak wavelength of 450 ± 20 nm not less than 8 μW/cm 2/nm is applied to the greatest possible surface area of the infant.
The light sources are usually special blue fluorescent lamps, compact florescent lamps (CFL) or halogen spotlights. If none of these are available, ordinary commercial white/daylight fluorescent lights should be considered, but brought as close as possible (10-20 cm) to the baby without overheating. ➢ → Light-emitting diode Phototherapy (LED-PT): Phototherapy devices which emit most of their light in the 450–470 nm spectrum.
This range corresponds to the peak absorption wavelength (458 nm) at which bilirubin is broken down. Blue LEDs are power efficient, portable devices with low heat production so that they can be placed very close to the skin of the infants without any apparent untoward effects. ➢ → Intensive Phototherapy (IPT): Phototherapy in which a high intensity of blue light (400–520 nm) ≥30 μW/cm2/nm is applied to the greatest possible surface area of the infant. In usual clinical situations, this will require special high-intensity fluorescent tubes, or CPT lamps placed approximately 30 cm (10 cm for cool blue light) above the infant, who can be nursed in a bassinet.
➢ → Filtered Sunlight Phototherapy (FS-PT): Treatment with specially filtered sunlight using custom pre-tested window-tinting films that protect against potentially harmful ultra-violet and infra-red rays. Primary prevention The contribution of maternal/family knowledge gaps regarding the importance of neonatal jaundice commonly manifesting in late presentation of infants with severe hyperbilirubinaemia to health services in LMICs is well documented. Mothers and families are able to detect jaundice from yellowish discolouration of the skin in their newborns accurately, if appropriately educated. Educating pregnant women, especially primigravidae during antenatal clinics, on the risks and adverse consequences of severe hyperbilirubinaemia, avoidance of potentially harmful traditional/herbal therapies and the mis(use) of haemolytic agents should be a priority. Routine determination of mother’s blood type and timely provision of anti-D globulin should be widely promoted to prevent Rh and neonatal jaundice due to other haemolytic diseases ,. Educational interactions with mothers and families must also recognise and seek to address common barriers to appropriate health-seeking behaviour for childhood illnesses. Although most infants are born outside hospitals in many LMICs, pre-discharge counselling of mothers who deliver in hospitals on the risks of hyperbilirubinaemia after discharge should be considered.
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Infants that are exclusively breastfed have an increased risk for severe hyperbilirubinaemia in the first 2 to 5 days of life compared to formula-fed infants. It is therefore, essential to provide good lactation support to all mothers at all levels of care to increase successful breastfeeding, at least 8–12 times a day, as breast-milk benefits outweigh the risk ,. Mothers, families and their jaundiced infants will also be best served by information provided during antenatal care, about hospitals in their communities that are able to provide requisite support for neonatal hyperbilirubinaemia.
Mothers who deliver at home, especially those who do not attend antenatal clinics present a special challenge that must be appropriately addressed in various communities. The inclusion of neonatal jaundice in the WHO recommended training on essential newborn care for traditional/home birth attendants, community and lay health workers should be considered in such settings -. The training should also be geared towards avoidance of haemolytic agents or traditional therapies, early recognition of the onset of jaundice by mothers and care givers, and surveillance for timely presentation to the nearest health facility. Early detection, diagnosis and monitoring Early identification of infants at risk of severe hyperbilirubinaemia is an essential component of newborn care. All newborns at all levels should be examined within 24 hours of birth and in the following two days. Mothers and other care-givers should be encouraged to look for jaundice by blanching the skin (on the nose in particular), looking at the gums and examining the eyes. The use of Kramer’s chart (see Additional file: Figure S1) especially in primary care settings remains valuable despite its limitation in correlating with the severity of jaundice ,.
So also is blanching of the gums possibly with an icterometer, particularly in dark-skinned babies. Healthcare professionals and parents are capable of recognizing jaundice, but not very good at assessing its severity. Notwithstanding, this visual assessment is generally more reliable and helpful in ruling out hyperbilirubinaemia than estimating bilirubin levels. The suggested pathways of care for all babies, adapted from NICE guidelines, are described in Figure.
At a minimum, infants with gestational age.
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