TEAM C SURVIVAL GUIDE
Special
thanks to Carly Varela, Katie Smentek and Patty Seo-Mayer
for
putting together this handbook.
This packet contains
a compilation of materials to keep you busy during your time on team C.
The problem section has been designed to give you exercises that
will be similar to those you will need to calculate daily when in the
NBSCU. While on Team C, you
should pre-round on a patient you will be following when you transition
over to the NBSCU team. Compare
your results with those the team A/B resident reports during rounds.
Write down everything that you don't understand on rounds and ask
the Team C practitioner to go over those things with you after rounds.
During this time, you should be getting familiar with the blue
book (NBSCU bible) online and the NRP book.
Remember, this survival guide is meant to be a supplement to the
materials mentioned above and to texts and other journal articles you
may come across during your time in the NBSCU.
Good Luck!
Helpful
hints to leaving post-call by 1pm
·
When
possible, examine your patients in early hands-on hours before rounds
(4-6am). Ask nurses when
these times are.
·
Write
skeleton notes prior to rounds.
·
Use
the portable SCM computer during rounds to put in orders during rounds.
One resident can put in orders while the other is presenting.
For stat orders that need phone calls (radiology studies, consults),
you can briefly step away from rounds to complete these tasks.
·
When
you are post-call, you should listen to teaching points, but you can also
use the time when other people are presenting to work on notes.
·
When
you are not post-call (and especially when you are on-call) you should
pay close attention to all the patient presentations and discussion on
rounds.
NICU Problems
- A. Your patient weighs 2kg. You found out on rounds this morning that his total fluid (TF) should be 130cc/kg/day. He will start TPN today with Protein of 1g/kg/day, Fat (IL) of 1g/kg/day and Dextrose of 10%. Calculate your patient's protein in g/L, fat in cc/day, total calories (TC), and rate of TPN. Hurry, your order needs to be in by 1pm.
B.
Your patient has been advancing TPN every few days.
On rounds this morning, you decided to increase to a P of 2.5,
F2, D15 keeping TF the same (130cc/kg/day).
Calculate as per question #1.
C. Your patient took a turn for the worse and is started on a dopamine drip in NS @ 1cc/h. You need to keep total fluid at 130cc/kg/day. As above, D15%, P2.5, F2. Please recalculate your TPN so it meets the above criteria.
D.
Your patient has been successfully weaned off of his dopamine drip
and is starting enteric feeds. He
will start 3cc Q3h of Enfamil w/Fe (PO/PG).
Assuming he is tolerating his feeds, how many kcal/kg/day does
he get from his PG feeds? How
many kcal/kg/day is he getting altogether (including TPN) adjusting TPN
rate when enteral feeds start?
2.
One of your fellow interns has a bad case of gastroenteritis and
you have been dialed to the NICU.
One of your patients is a 500g five day old ex 24 week baby boy
born to a G7P3Ab4 serology negative, GBS negative, HIV negative 20yo mother
who had a positive urine toxicology screen for cocaine.
Your patient is ventilator dependent and has just completed a 48h
course of Amp and Gent for a r/o sepsis evaluation.
This patient is on TPN of D7.5 P25 @ 2.8cc/h and IL @ 0.23cc/h.
You are just slightly overwhelmed, but know that in the morning,
you will need to report P and F in g/kg/day, TF in cc/kg/day, and TC in
kcal/kg/day and your patient’s GIR.
Get to work!
3.
Another one of your patients has recently graduated to room 1. He is an ex 27 week male who was ventilator dependent in the
past, but is now thriving on room air with only occasional episodes of
apnea. He is on caffeine
for his apnea, and as far as feeds are concerned, is on a standard formulation
of Enfamil Premie (24kcal/oz) at 30cc q3h.
You need to increase his daily caloric intake so he will be big
enough to go home. How can
you increase the calories without increasing total fluid?
How many kcal/kg/day is he getting now?
4.
Your patient is 3kg and she is getting D15 P30 @18cc/h, F27 @2cc/h.
How many kcal/kg/day is she getting?
What is her P, F, and GIR?
What is her total fluid?
5.
On the above regimen, Baby Girl Jones has d-sticks of 180-220. What changes do you need to make? Recalculate the dextrose portion of her TPN.
6.
Baby girl Smith is a 7 day old with a K of 2.6 and weighs 3kg. She is getting TPN w/D15P3@10cc/h and F3@2cc/h w/20meq/L of
KCL. Her urine output has
been roughly4cc/kg/h with a recent Cr of 0.4.
How many meq/kg/day of KCl is she currently getting? Double the
KCl in her TPN. What will
be the new meq/kg/day with the new regimen?
How much KCl in meq/l should you order if you want to give 5meq/kg/day?
7.
Your patient is ventilator dependent.
Current settings are SIMV 16 PIP 20
PEEP 5 and FiO2 40%. His
nurse tells you he has been fussy all morning w/more frequent desaturations. You ask for an arterial blood gas. On the above settings it is 7.21/70/50/26.
What does this mean for your patient, and how can you correct it?
8.
You are called to a delivery secondary to meconium for a 393
G3 P2 serology negative, GBS +, HIV neg, healthy 32yo F.
The DR RN tells you that mom received 2g IV Ampicillin 6h ago,
and 1g 2h ago. The infant
is delivered and brought to the radiant warmer where you suction, dry,
and stimulate him following the NRP guidelines.
Your assessment is a healthy term male infant and as you are wrapping
him, you notice he has some nasal flaring and is grunting, but has pink
color throughout. What should
you do for this infant? What
are you concerned about?
9. You are called to a delivery for a G2 P1 386 serology neg, GBS neg, HIV neg, class B 36 yo diabetic mother. You are told that mom’s sugars have been relatively well controlled on insulin during pregnancy. A large appearing female infant is delivered vaginally, cries spontaneously and is brought to the radiant warmer where you proceed with appropriate resuscitative efforts, following the NRP guidelines. What needs to be done for this infant after the initial resuscitation is complete? What scenarios should you be thinking about in this infant?