Pediatrics- NICU

Consults to the NICU can come for a variety of different places.

• Planned C-section of baby who needs resuscitation/monitoring in NICU

• Emergency C-section of baby who needs resuscitation/monitoring in NICU

• Code-pink (which basically means fetal distress) delivery on LDR and baby needs resuscitation/monitoring in NICU

• Baby delivery in LDR who deteriorates and needs resuscitation/monitoring in NICU

• Sick baby born in different town and transfer to Prince George NICU

• Sick baby who was being cared for at BC Children's, but is now 30 weeks and can be transfer back to Prince George NICU (PG only cases for babies 30 weeks GA and older)

Despite the variety of circumstances in which babies can arrive in the NICU, your approach to their consult is generally the same. The only exception is if the baby is at a higher level NICU and gets transferred to PG, then they will come, hopefully, with a transfer package, that will include all of the care/interventions they have received while at the previous hospital. Otherwise, your general approach is often to review the mother’s paper chart and PowerChart, which includes the antenatal record, newborn record, and resuscitation record. Remember to review the ultrasound reports yourself on PowerChart.

Conducting a consult in NICU is quite different from other specialties, as most of the information comes from records and PowerChart, as opposed to from the patient. The below format can be used for both C-section notes (a dictated note must be done for all C-sections attended by peds, which is all C-sections), as well as code pinks. Sometimes, a baby will come over to NICU without a parent (they may still be in LDR or post-op recovery), so you won’t even have someone to ask questions to. If a parent does come over, it is always a good idea to talk to them and confirm information about the pregnancy you got from the antenatal record with them.

When it comes to doing your physical exam for the consult, the goal is to do a full head to toe newborn exam. This may not always be possible (for example, if the baby is on CPAP and you are not able to pick up the baby and do certain exam components). That is okay, just document that, so that you can do those exam components at a later time.

Maternal Hx: Includes three main categories: 1. Maternal PMHx 2. Medications and 3. Social history, particularily substance use, supports, etc.

Past OBHx: This information will be found in the antenatal record

Current Pregnancy

1. Prenatal: found on the antenatal record and Powerchart, including serology and genetic information if available

2. Ultrasounds: Include each of the U/S, particularly noting the growth parameters- with percentile & associated GA, any anatomical or placental abnormalities and fluid levels.

3. Complications: Include any complications with the pregnancy (GDM, pre-eclampsia), as well as any substance use during the pregnancy

4. Labour and Delivery: concise summary of labour. Important features include:

• GBS status +/- ABx

• Analgesia used

• Rupture of membranes- mec?

• FHR tracing pattern- reassuring or concerns

• What ultimately prompted Peds consult (eg: emergency C-section, abnormal FHR tracing)

Resuscitation: If any resus was required, include summary here. Detailed record is documented during any resus and is a good guide to use for this section. This can include resus that occurred initially after delivery, or anything started hours later (Eg: CPAP started 3 hours after delivery)

Newborn Exam: Every time you examine a baby, you do a full head-to-toe exam. Everytime! Also, make sure you document the full exam.

Before you call your attending, it is a good idea to have written down your main points in an organized fashion so when you present, it is concise and to the point. For peds, the attendings love detail. That doesn’t mean you need to include every single little thing in your presentation. You want to include all of your important pertinent positives and negatives, and have more detail ready if they ask for it. It will take time and practice (all of third year and beyond), to begin to feel more confident with presenting to your attending and determining what to include and not to.

When writing admission orders for NICU, ADDAVID is a good approach. A couple notes for NICU:

1. Diet: This can be particularly difficult in NICU. This is something you will learn more about during your rotation, but there are a lot of different components to diet in NICU. If a patient is breastfeeding ad lib (as needed), you can just include that, but if you are putting them on a prescribed diet, you need to include: what (formula- what kind vs. breast milk vs TPN), any additives (eg: calorie additives…), what route (bottle vs. NG vs IV) and the minimum total fluid intake (TFI).

2. Activity: If a baby is in isolation, you can include that here.

3. Drugs: When prescribing anything in NICU/Peds, look up EVERYTHING. The website used by all pediatricians is the BC Children’s and Women’s Hospital Online Formulary. Bookmark this page and use it to look up all dosing for drugs. Everything in pediatrics is weight based dosing- include your mg/kd/dose so calculation can be double-checked.

Rounding in NICU will look different depending on the attending. However, it always starts with you pre-rounding before the attending arrives. You will arrive before the attending and collect all of the information for the note from the nursing notes (most of it will be found there) and powerchart. Then, once the attending arrives, you will present your patient’s note to the team, and go in and see the baby and their parents (if they are present). It is a good idea to keep a list on the first page of the notes of all the active/ resolved issues. That way, when you have to do the discharge summary, all of the issues are conveniently summarized. The following are some explanation of the NICU rounding notes:

• GA: gestation age the baby was born at

• cGA: corrected gestational age: the age the baby is now, after X days of life

• DOL: day of life: number of days since delivery, at UHNBC delivery day is DOL 0, first day after delivery= DOL 1

• Weight: include the birthweight and that day's current weight. It is also good to trend the gain/loss. Every couple of days, do a 3 or 5 day average (Eg: 5 day average: add up all of the losses/gains then divide by 5). Note it is normal for babies to lose weight for the first 10-14 days. Additionally, the presence of lines/CPAP may influence the weight.

• Vital signs: include the most recent. When presenting, some attendings like all vitals read, while others just like abnormal vitals identified. It can also be a good idea to review the trends of the vitals over the past few days

• Medications: review either the MAR (found in the med area, or the orders) to ensure you are getting the most up to date list. It is also a good idea to include the dosing per weight as opposed to the total dose in mg (eg. 50mg/kg/dose vs. 205mg)

• Feeding: include total intake, minimum TFI/ad lib, type of intake, route, and percentage oral

• ABDs: These are apneas, bradycardias and desats (these are more common in premature babies). Include how many, the type, the intervention required, how long they lasted, is there any pattern with them (eg: only happen with feeds).

• Problem list: include status, any new investigations/ results, and plan.

• Routine: these things happen for all newborn babies. They include things like the hearing screen and metabolic screen. You can check the 2nd page of the newborn record to see if they have been done/drawn.