Sinh để rất đẹp, kỳ diệu, và có lẽ là sự kiện nguy hiểm nhất mà hầu hết chúng ta từng gặp phải trong cuộc đời của mỗi người.Cơ thể chúng ta được yêu cầu phải thực hiện nhiều điều chỉnh sinh lý triệt để ngay lập tức sau sinh hơn họ sẽ không bao giờ phải làm lại. Đáng chú ý là hơn 90% trẻ sơ sinh làm cho quá trình chuyển đổi từ trong tử cung để cuộc sống ngoài tử cung hoàn toàn trơn tru, với ít hoặc không có sự hỗ trợ cần thiết. Vài phần trăm còn lại được cho rằng do Chương trình hồi sức Sơ sinh (NRP) thiết kế. Trong khi tỷ lệ trẻ sơ sinh cần hỗ trợ có thể là nhỏ, con số thực tế của trẻ sơ sinh cần giúp đỡ là đáng kể vì số lượng lớn các ca sinh. Các tác động của không nhận được sự giúp đỡ có thể được kết hợp với những vấn đề mà một suốt đời hoặc thậm chí với cái chết.
Editors: MacDonald, Mhairi G.; Ramasethu, Jayashree Title: Atlas of Procedures in Neonatology, 4th Edition Copyright ©2007 Lippincott Williams & Wilkins > Front of Book >OFEditors UNREGISTERED VERSION CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Editors Mhairi G MacDonald MBChB, FRCPE, FRCPCH, FAAP, DCH UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Professor of Pediatrics George Washington University, School of Medicine and Health Sciences, Washington, DC, The Accreditation Council of Graduate Medical Education, Chicago, Illinois Jayashree Ramasethu MBBS, DCH, MD, FAAP Associate Professor of Clinical Pediatrics, Associate Director Neonatal - Perinatal Medicine Fellowship Program, Division of Neonatology, Georgetown University Hospital, Washington, DC Secondary Editors Sonya Seigafuse Acquisitions Editor Ryan Shaw Managing Editor Alicia Jackson Production Editor Benjamin Rivera Senior Manufacturing Kimberly Manager Schonberger Marketing Manager Doug Smock Creative Director Mark Flanders Art Director for Media Services TechBooks Compositor R R Donnelley-Asia Printer Contributing Authors M Kabir Abubakar MBBS, FAAP Associate Professor of Clinical Pediatrics Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Monisha Bahri MBBS Fellow in Neonatal-Perinatal Medicine Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Aimee M Barton MD, FAAP Fellow in Neonatal-Perinatal Medicine Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Alan Benheim MD Pediatric Cardiology Associates, P.C Fairfax, Virginia; Assistant Clinical Professor, Inova Fairfax Hospital for Children, Falls Church, Virginia A Alfred Chahine MD Associate Professor UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Department of Pediatric Surgery, The George Washington University School of Medicine; Chief, Department of Pediatric Surgery, Georgetown University Hospital, Washington, DC UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Robert D Christensen MD Medical Director Neonatology, Urban Utah North Region, Intermountain Healthcare, Ogden, Linda C D'Angelo RN, BSN, CWOCN Wound, Ostomy, and Continence Nurse, Nursing Department, Georgetown University Hospital, Washington, DC William F Deegan MD Associate Clinical Professor Department of Ophthalmology, George Washington University School of Medicine, Attending Surgeon, Department of Ophthalmology, Children's National Medical Center, Washington, DC Jennifer A Dunbar MD Assistant Professor of Ophthalmology Department of Ophthalmology, Loma Linda University School of Medicine; Attending Physician, Department of Ophthalmology, Loma Linda University Medical Center, Loma Linda, California Martin R Eichelberger MD Professor of Surgery and Pediatrics Department of Surgery, The George Washington University School of Medicine; Attending Pediatric Surgeon, Department of Pediatric Surgery, Children's National Medical Center, Washington, DC Rebecca J Eick MD Fellow in Neonatal-Perinatal Medicine Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Laura A Folk RNC, BSN, Med Clinical Educator Neonatal Intensive Care Unit, Georgetown University Hospital, Washington, DC Chrysanthe G Gaitatzes MD, PhD Neonatology Fellow Department of Pediatrics, George Washington University Hospital, Neonatology Fellow, Department of Neonatology, Children's National Medical Center, Washington, DC Harold M Ginzburg MD, JD, MPH Clinical Professor Department of Psychiatry, Tulane University Health Sciences Center, LSU Health Sciences Center, New Orleans, Louisiana; Adjunct Professor, Psychiatry, Uniformed Services University of the Health Sciences School of Medicine, Bethesda, Maryland Allison M Greenleaf RN, MSN, CPNP Pediatric Nurse Practitioner Department of Pediatrics, Division of Neonatology, Georgetown University Hospital, Washington, DC Leah Greenspan-Hodor DO Neonatal-Perinatal Fellow Department of Neonatology, Children's National Medical Center, Washington, DC Gary E Hartman MD Clinical Professor of Surgery UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Division of Pediatric Surgery, Stanford University School of Medicine; Director, Regional Surgical Services, Lucile Packard Children's Hospital, Stanford, California UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Hosai Hesham MD Resident Physician Department of Otolaryngology, Head and Neck Surgery, Georgetown University Hospital, Washington, DC Pamela Jakubowicz MD Assistant Professor Department of Medicine, Albert Einstein College of Medicine, BronxLebanon Hospital Center, Bronx, New York Margaret Mary Kuczkowski MSN, CPNP Clinical Educator Neonatal Intensive Care Unit, Georgetown University Hospital, Washington, DC Naomi L C Luban MD Professor Departments of Pediatrics and Pathology, George Washington University School of Medicine and Health Sciences; Chairman, Laboratory Medicine and Pathology; Director, Transfusion Medicine; Vice Chairman, Academic Affairs, Department of Laboratory Medicine, Children's National Medical Center, Washington, DC Mhairi G MacDonald MBChB, FRCPE, FRCPCH, FAAP, DCH Professor of Pediatrics George Washington University, School of Medicine and Health Sciences, Washington, DC, The Accreditation Council of Graduate Medical Education, Chicago, Illinois Secelela Malecela MD Fellow in Neonatal-Perinatal Medicine Division of Neonatology, Department of Pediatrics, Georgetown University Children's Medical Center, Washington, DC Kathleen A Marinelli MD, IBCLC, Associate Professor of Pediatrics Department of Pediatrics, University Farmington, Connecticut; Attending Neonatology, Connecticut Children's Connecticut FABM, FAAP of Connecticut School of Medicine, Neonatologist, Department of Medical Center, Hartford, Nicholas J Marsh DO Attending Anesthesiologist Department of Anesthesiology, INOVA Loudoun Hospital Center, Leesburg, Virginia An N Massaro MD Adjunct Instructor in Pediatrics Department of Pediatrics, George Washington University; NeonatalPerinatal Fellow, Department of Neonatology, Children's National Medical Center, Washington, DC Marijean Miller MD Associate Professor Departments of Ophthalmology and Pediatrics, George Washington University; Attending, Department of Ophthalmology, Children's National Medical Center, Washington, DC Gregory J Milmoe MD, FAAP Associate Professor Department of Otolaryngology - Head and Neck Surgery, Georgetown University Hospital, Washington, DC UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Susan H Morgan MEd Instructor, Director of Audiology and Hearing Research Department of Otolaryngology-Head and Neck Surgery, Georgetown UNREGISTERED CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE University VERSION Hospital,OFWashington, DC Robert J Musselman DDS Clinical Professor of Pediatric Dentistry Louisiana State University School of Dentistry, New Orleans, Louisiana Sepideh Nassabeh-Montazami MD Assistant Professor of Pediatrics Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Khodayar Rais-Bahrami MD Professor of Pediatrics Department of Pediatrics, The George Washington University School of Medicine; Attending Neonatologist, Department of Neonatology, Children's National Medical Center, Washington, DC Jayashree Ramasethu MBBS, DCH, MD, FAAP Associate Professor of Clinical Pediatrics; Associate Director Neonatal - Perinatal Medicine Fellowship Program, Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Majid Rasoulpour MD Professor Department of Pediatrics, University of Connecticut School of Medicine, Farmington, Connecticut; Chief, Pediatric Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut Mary E Revenis MD Assistant Professor Department of Neonatology/Pediatrics, The George Washington University School of Medicine and the Health Sciences; Attending Neonatologist, Department of Neonatology, Children's National Medical Center, Washington, DC Lisa M Rimsza MD Associate Professor Department of Pathology, University of Arizona, Department of Pathology, University Medical Center, Tucson, Arizona Dora C Rioja-Mazza MD Fellow in Neonatal-Perinatal Medicine Division of Neonatology, Department of Pediatrics, Georgetown University Hospital, Washington, DC Priyanshi Ritwik BDS, MS Assistant Professor Department of Pediatric Dentistry, Louisiana State University, Baton Rouge, Louisiana; Clinical Director, Special Children's Dental Clinic, Children's Hospital of New Orleans, New Orleans, Louisiana Jeanne M Rorke RNC, NNP, MSN Neonatal Nurse Specialist Neonatal Intensive Care Unit, Georgetown University Hospital, Washington, DC Thomas T Sato MD Staff Surgeon Division of Pediatric Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Billie Lou Short MD Professor Department of Pediatrics, George Washington University School of Medicine; Chief, Division of Neonatology, Department of Neonatology, UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Children's National Medical Center, Washington, DC Martha C Sola-Visner MD Associate Professor Department of Pediatrics, Drexel University, Attending Neonatologist, Department of Pediatrics/Neonatology, St Christopher's Hospital for Children, Philadelphia, Pennsylvania Rachel St John MD Assistant Professor, Director Kids Clinic for the Deaf, Department of Pediatrics, Georgetown University Hospital, Washington, DC Cynthia J Tifft MD, PhD Associate Professor Department of Pediatrics, The George Washington University School of Medicine and Health Sciences; Chief, Division of Genetics and Metabolism, Children's National Medical Center, Washington, DC Dawn M Walton MD Associate Clinical Professor of Pediatrics George Washington University School of Medicine, Washington, DC, Neonatologist, Community Neonatal Associates, Holy Cross Hospital, Silver Spring, Maryland TABLE B.2 Selected Sutures Appropriate for Common Neonatal Procedures UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE P.400 P.401 P.402 P.403 Appendix C: Chapter 41 TABLE C.1 Blood Products UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE P.404 Appendix D: Chapter 34 Techniques for Endotracheal Intubation Specific to Unique Patient Needs Elective Change of Orotracheal Tube in Intubated Patient This procedure allows continued ventilation through a pre-established airway whenever it is necessary to change an endotracheal (ET) tube or to place a nasotracheal tube By maintaining the original airway as long as possible during t change, there is less need for haste and less stress to the patient An obvious prerequisite is that the original ET tube be patent and correctly positioned in the trachea Rapid Replacement Method Prepare equipment and patient as for initial orotracheal intubation Release tube fixation device without displacing tube Have assistant hold first ET tube in place at far left of the infant's mouth while continuing to ventilate infant Visualize glottis with laryngoscope Pass second orotracheal tube down far right of the mouth until it aligns with glottic opening When new tube is positioned for direct insertion, have assistant withdraw first tube carefully Advance new tube into position Verify position and secure tube as previously described Alternative Tube Method: Insertion over a Feeding Because of the narrow diameter of ET tubes in small infants, feeding tubes narrow enough to fit inside the ET lumen are often too flexible to stay within the trachea as the tubes are being changed Be prepared to intubate directly should the feedin tube dislodge Prepare equipment and patient as for initial orotracheal intubation Release tube fixation device without displacing tube Select the largest feeding tube that will easily go through the current and new endotracheal tubes Remove the flared end of feeding tube and the adaptor on the new tube Remove adaptor of currently in-place ET tube Quickly insert the feeding tube through the lumen to a depth not greater than the ET tube While holding feeding tube in place, pull ET tube out of trachea and off feedin UNREGISTERED tube VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Slide new ET tube over feeding tube into trachea Replace tube adaptor UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Verify position and secure tube as previously described Selective Left Endobronchial Intubation The angles of the bronchi are such that more often than not a tube will seek the right mainstem bronchus The exceptions will be conditions that push the left side down (left upper-lobe emphysema) or that pull the right side up (marked upperlobe atelectasis or hypoplasia) Normally, successful right mainstem intubation simply requires a longer tube Selective intubation of the left bronchus is a more difficult and dangerous procedure; therefore, following all precautions is especiall important Place the ET tube under guidance by direct bronchoscopy or under fluoroscopy when these procedures are available without compromise to infants (1 ,2 ) The following procedure is a simple, indirect method based on a modification that tends to make the ET tube bend toward the left when it meets resistance at the carina (3 ) Cut an elliptical hole through half the diameter of ET tube cm in length and 0.5 cm above the tip of the oblique distal end Perform an orotracheal intubation as above, keeping the cut hole directed toward the left lung Turn infant's head toward the right (4 ) While auscultating the lung fields, advance the tube to 0.5 to cm below the calculated depth of the carina or until differential breath sounds are heard If breath sounds diminish on the left, withdraw the ET tube until they return Take a chest radiograph to confirm left bronchial position Fix tube securely Reassess position frequently, as tube may dislodge from one mainstem into th other P.405 Follow patient closely for particular complications of Air leak of ventilated area Stasis pneumonia of nonventilated area Dislodgement from left mainstem bronchus Ventilatory insufficiency due to significant disease in the only lung being ventilated Nonvisualized Oral Intubation This technique has a higher risk of complications and is less often successful than when direct visualization is used Reserve the blind oral intubation for true emergencies in small infants when there is equipment failure (e.g., laryngoscope light) and when ventilation by mask is contraindicated (e.g., thick meconium) Stand at infant's feet Carefully slide first two fingers of gloved, left hand into back of oropharynx at the base of tongue, until reaching vallecula and epiglottis Keep fingers in the center of the tongue Using index finger, pull epiglottis forward Keep infant's head in midline With right hand, guide ET tube, without stylet, along left middle finger, which held just above index finger Advance tube carefully just beyond fingertips Avoid pushing against any obstruction If available, have assistant press gently on trachea in suprasternal notch and UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE report when tube passes under finger Verify position, and fix tube as previously described UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE Blind Nasotracheal Intubation (5) Blind nasotracheal intubation is often used in adults Because a stiff tube is neede the chance of perforation in infants is greater if a stylet is used Although an intubation under direct visualization is preferred, the presence of severe microagnathia or oral masses makes this approach valuable It is critical not to push against any resistance Keep infant supine with neck flexed and shoulders supported by a small roll Shape a stylet so the tip of the endotracheal tube will curve anteriorly at 90 degrees Be certain the tip of the stylet stays above the end of the ET tube Alternately, freeze an ET tube in this configuration and remove stylet just prio to insertion Maintaining the curve in the tube anterior, insert the tube carefully through th nostril until its tip is in the oropharynx Pull the jaw forward into a sniff position with the head midline and put slight external pressure over the cricoid cartilage Advance the tube to a suitable depth unless there is any resistance Remove stylet and verify presence of exhaled humidity and equal breath sounds Intubation in Severe Cleft Defects There are several possible modifications for ET tubes that are useful for fixation o elective intubation when there is a large cleft palate For emergency intubations, the following modification using a standard tongue blade is usually immediately available (6 ) For techniques or difficult intubation alternatives, see above (7 ) Open infant's mouth and lay sterile tongue blade flat across maxilla, with end extending from corners mouth Have assistant hold in place Follow steps for routine intubation, using tongue blade for support of laryngoscope as necessary After intubation, fix tube to padded tongue blade Recognize that tongue thrust on tube in absence of a normal palate may lead extubation even without visible external lengthening of tube Emergency Retrograde Intubation (8) When facial anomalies preclude other routes, retrograde intubation using a modified Seldinger technique is possible Because the cartilaginous support of the trachea is so poor, needle puncture is far more difficult in neonates Equipment Venous cannula with stylet, 14 or 16 gauge Feeding catheter Verify that the catheter will pass through the lumen of the angiocath A 14-gauge cannula will admit a 5-French (Fr) feeding tube A 16-gauge cannula will admit a 3.5-Fr feeding tube Hemostat Endotracheal tube P.406 Technique Sedate infant if possible Clean skin over cricothyroid area UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE At the level of the cricothyroid, puncture skin with cannula and stylet Angle cannula at 45 degrees from the skin and directed toward the head Insert into lumen or trachea only until there is a give in resistance or air UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE returns Remove the stylet Thread feeding tube through the lumen of the cannula until it can be retrieved from the nose or oropharynx Bring cephalic end of feeding tube out of the nose or mouth, leaving other end well outside skin insertion While feeding tube is in place, remove the cannula from the tracheal insertion site Clamp the feeding tube at its tracheal insertion so it will not be pulled into the trachea farther than desired At the upper end, slip the ET tube over the feeding tube and along its course until it has passed the proper distance into the trachea Stabilize the ET tube Cut the feeding tube at its tracheal insertion While keeping the ET tube in place, pull the feeding tube through the ET tube Secure ET tube after verifying correct intratracheal position References Georgeson K, Vain N Intubation of the left main bronchus in the newborn infant: a new technique J Pediatr 1980;96:920 Mathew O, Thach B Selective bronchial obstruction for treatment of bullous interstitial emphysema J Pediatr 1980;96:475 Weintraub Z, Oliven A, Weissman D, Sonis A A new method for selective left main bronchus intubation in premature infants J Pediatr Surg 1990;25:604 Sivasubramanian K Technique of selective intubation of the left bronchus in newborn infants J Pediatr 1979;94:479 Williamson R Blind nasal intubation of an apneic neonate Anesthesiology 1988;69(4):633 Zawistowska J, Menzel M, Wytyczak M Difficulties and modifications of intubation technique in infants with labial, alveolar and palatal clefts Anaesth Resusc Intens Ther 1973;1:211 Stool SE Intubation techniques of the difficult airway Pediatr Infect Dis J 1988;7:154 Cooper CM, Murray-Wilson A Retrograde intubation Management of a 4.8 kg, month infant Anaesthesia 1987; 42:1197 P.407 P.408 Appendix E: Chapter 50 TABLE E.1 Drugs Requiring Adjustment in Severe Renal Failure UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE UNREGISTERED VERSION OF CHM TO PDF CONVERTER PRO BY THETA-SOFTWARE