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  • image Pharmacokinetic parameters are altered across the age spectrum of the neonatal population (ie, preterm to term) because of developmental maturation and the effect of various disease states on these processes. Therefore, medication selection and monitoring is of utmost importance in this population.

  • image Treatment guidelines for neonatal resuscitation have been extrapolated from studies in older children and adults which may not be optimal because of differences in the pathophysiology of cardiopulmonary arrest among these populations.

  • image Neonatal sepsis can be categorized as either early-onset sepsis (EOS) or late-onset sepsis (LOS). Pathogens associated with neonatal sepsis vary depending on the onset of sepsis (EOS vs LOS).

  • image Empiric antibiotic therapy should be initiated in infants with suspected sepsis and should target the most common pathogens.

  • image Patent ductus arteriosus occurs commonly in preterm neonates and, if hemodynamically significant, requires pharmacologic (with a cyclooxygenase inhibitor) or surgical closure.

  • image In certain congenital heart defects (eg, tetralogy of Fallot, hypoplastic left heart syndrome, transposition of the great arteries), it is imperative that the ductus arteriosus remains patent. Prostaglandin E1 (alprostadil) is the drug of choice in these cases.

  • image Neonatal hypotension can result in impaired cerebral perfusion and ischemic damage if left untreated. Because there is no clear consensus on the definition of neonatal hypotension, clinical judgment and review of the physiological parameters of the infant are important when making diagnosis and treatment.

  • image Pharmacologic therapy should be selected based on the etiology of hemodynamic instability and may include fluid bolus, vasopressors (such as dopamine, dobutamine, epinephrine, and norepinephrine), hydrocortisone, and vasopressin. Dopamine is the preferred initial vasopressor agent for hemodynamic support in neonates with hypotension.

  • image Assessment of the degree of pain and sedation in the preverbal neonatal population is difficult. Assessment tools should be used, but it is important to recognize the population and pain type for which each tool has been validated.

  • image Opioids and benzodiazepines are commonly used to provide analgesia and sedation for critically ill neonates; however, there are concerns about their effects on long-term neurodevelopment.


Patient Care Process for Neonatal Critical Care



  • Patient characteristics (eg, gestational age, postnatal age; see Table e21-1)

  • Birth history (eg, ultrasound findings, timing of rupture of membranes, presence of maternal fever, Apgar scores, prenatal betamethasone, and antibiotic therapy)

  • Maternal history (eg, disease states, medications during pregnancy including alcohol and illicit agents)

  • Current medications including surfactant, antibiotics, intravenous fluids, and parenteral nutrition orders

  • Objective data

    • Blood pressure (BP), heart rate (HR), respiratory rate (RR), length, weight, O2-saturation

    • Labs including electrolytes, blood urea nitrogen (BUN), serum creatinine (SCr), C-reactive protein (CRP), white blood cell count (WBC) and differential, cultures

    • Maternal serologies (eg, Group B Streptococcus, hepatitis B, syphilis, HIV)


  • Hemodynamic stability (see Table e21-5), evidence of peripheral perfusion (eg, capillary refill, peripheral pulses)

  • Respiratory status (eg, grunting, flaring, retractions, need for respiratory support)

  • Kidney function (eg, urine output, BUN, SCr)

  • Pain (see Table ...

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