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ICN3 Reminders and Calculators

Page history last edited by Dan Waldman 6 years, 5 months ago

ICN 3 CLINICAL REMINDERS AND CALCULATIONS

 

(Please obtain attending approval for all patient management decisions.)

 

Weight: Document wt. loss or gain from previous day, as well as % down from birth wt.

 

Input: Document:

cc/dayof formula or expressed breast milk.

cc/kg/dayof formula or expressed breast milk. (One ounce usually has 20 kcal, although sometimes is increased to 22 kcal. There are 30 cc in one ounce.)

 

An example:

320 cc total formula and expressed breast milk intake for a 2.8 kg infant

= 320cc/2.8kg =114 cc/kg/day.

=114 cc/kg/day (20/30) = 76 kcal/kg/day

 

If on IVF, Kcal/kg/day = (%dextrose)(0.034)(cc/day)

Wt (kg)

 

Output: Document as number of wet diapers for infants with only po intake. Document as cc/kg/h for infants on iv fluid. Also document number of bowel movements and episodes of emesis.

 

Hypoglycemia:

GIR (glucose infusion rate)= (% glucose)(rate of infusion in cc/h)

(6)(wt in kg)

 

Generally start with GIR 4-6 (units are mg/kg/min)

Cannot use>12.5% with a peripheral line

Usually use 10%

Wean 1 GIR q 2-3 h, checking CBG/one touches qac.

Increase feeds accordingly.

 

Example: You wish to start a glucose infusion rate of 4 using D10 for an infant weighing 3.460 kg

 

4 mg/kg/min = (10%)(x)__ where x is the rate of the D10 drip

(6)(3.460 kg)

 

Solving for x, the rate of the D10 drip would be 8.3 cc/h.

 

 

Special Care Nurseries Feeding Guidelines:

 

Bolus Gavage Feeding

  • Initial volume is 3-5 cc/kg every 3 hours.

  • Additional needs for fluid are achieved with iv fluid. Total amount depends on gestational age, weight, and hours of life.

 

Continuous Gavage Feedings

  • Use if there is a question of whether or not bolus feeds will be tolerated.

  • Initial volume is 0.5-1cc/hr.

 

Nipple Feeding

  • Do not attempt nippling until 32-34 weeks due to poor coordination of suck/swallow.

  • 34-36 weeks: Initial volume of feeding can be 3-5 cc/kg q 3 hrs.

  • > 36 weeks: Ad libitum. Frequency of feeds q 3-4 hours usually.

  • If infant is not nippling as expected and medical complication (sepsis, respiratory distress, etc) has been ruled out, consider a Developmental Care consult (helps with positioning, pacing, etc.).

  • Good signs that nippling is going well:

    • No apnea, bradycardia, chocking, or cyanosis during feeds.

    • Ability to ingest the goal volume of feed in 30 minutes.

    • Adequate weight gain

 

Increasing the Volume of Gavage or Nippled Feedings

  • The decision to increase feedings is based on residual amount of formula/milk in the stomach if gavaged, emesis/spitting up and ability to take the entire feed if nippling, as well as passage of stool and absence of abdominal distention. .

  • > 1000g birth weight: Increase by 1.5-3cc q 6-12 hours as tolerated.

  • Remember to decrease the iv fluid rate accordingly.

 

Provision of Adequate Calories

  • Initially use 20cal/oz formula (E20)

  • Term infants (>37wks): Goal is 80-100 kcal/kg/day. This can be achieved by feeding 120-150cc/kg/day of E20 term formula.

  • Premature Infants (<37wks): Goal is 120 kcal/kg/day. In order to provide adequate calories and keep fluid intake at 150cc/kg/day, the caloric density of formula may need to be increased. This is done by increasing the caloric density to 22 or 24 kcal/oz.

 

(More detailed feeding guidelines can be found in the ICN3 Protocol Book.)

 

 

 

Bilirubin Levels for Phototherapy and Exchange:

 

Use “Bilitool” for newborns within the acceptable gestational age range (at least 35 weeks GA), as this provides an hour-specific recommendation for treatment and follow-up.

 

For newborns less than 35 and 0/7 weeks GA, refer to chart below (Courtesy of Care of the High Risk Neonate, pg. 68).

 

(These are only general recommendations, and treatment decisions will depend on patient-specific information.)

 

UNCOMPLICATED

BIRTH WT

<1000gr

1001 -1249g

1250 – 1999 g

1500 – 1999 g

2000 – 2499 g

2500+ g

Light Level

5

8

10

12

13

15

Exchange Level

10

13

15

17

18

20

 

 

COMPLICATED (see definitions below)

BIRTH WT

<1000g

1001 – 1249 g

1250 – 1499 g

1500 – 1999 g

2000 – 2499 g

2500 +

Light Level

5

5

8

10

12

13

Exchange Level

10

10

13

15

17

18

 

 

 

Complicated:

5 min APGAR <3, PaO2 <40mmHg for more than 1 hr, pH 7.15 for more than 1 hour, rectal temp <35 C, serum albumin <2.5mg/dl. Signs of CNS deterioration, sepsis or meningitis or evidence of hemolytic anemia.

 

White to Red Cell Ratio for CSF vs. Serum (For Bloody Tap)

 

Calculate WBC to RBC ratio in serum (RBC usually reported as millions):

 

WBC in serum (thousands) = Ratio for comparison to CSF

RBC in serum (thousands)

 

Calculate WBC to RBC ratio in CSF:

 

Nucleated cells in CSF = Ratio for comparison to serum

RBC in CSF

 

If WBC to RBC ratio higher in CSF, consider possibility of meningitis in context of other clinical data and findings such as CBC, cultures, etc.

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