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CHAPTER 6 Heat Balance
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159
Pulmonary vasoconstriction, accentuated by metabolic
acidosis, is associated with hypoxia, decreased surfactant production, and further acidosis (see Chapter 23).
Blood flow to vital organs is diminished, and pulmonary hemorrhage and death may occur if hypothermia
continues.
Hyperbilirubinemia and kernicterus may occur as
nonesterified free fatty acids from brown fat metabolism compete with bilirubin for albumin-binding sites.
Acidosis not only decreases the affinity of albumin
for bilirubin but also increases the permeability of the
blood-brain barrier, allowing bilirubin to enter brain
tissue. If hypothermia continues, carbohydrate, protein, and fat supplies will be used for heat production
instead of growth.
Close monitoring of the hypothermic infant is
essential for early identification and prevention of
complications. Evaluation of vital signs, arterial blood
gases, and oxygen saturation may give early indication of hypoxia and metabolic acidosis. The infant’s
skin may be dusky or bright red because failure of
dissociation of oxyhemoglobin occurs at low body
temperatures. Respirations may be rapid, shallow, and
grunting and accompanied by bradycardia. Oxygen
and ventilation should be initiated as needed to reduce
hypoxia. Sodium bicarbonate may be needed to correct documented metabolic acidosis. Seizures may
occur as a result of hypoxia, requiring the administration of anticonvulsants.
Intravenous glucose may be necessary to prevent or
correct hypoglycemia. Blood glucose levels should
be monitored hourly until stable (see Chapter 15).
Blood pressure and urine output should be measured to evaluate hydration and kidney function. An
elevated BUN and hyperkalemia may be indicators of
decreased renal perfusion and impaired renal function.
As fluid is retained, edema of the extremities and face
may occur.
Bilirubin should be monitored on a regular basis,
and phototherapy may be initiated at a lower-than-usual level to prevent kernicterus. Adequate nutrition to
promote growth should be given either intravenously
or enterally. While the infant is hypothermic, nipple
feedings should be avoided to conserve calories and
energy for heat production and growth and to avoid
aspiration. Hypothermic infants feed poorly and fail to
gain weight because calories are used to generate heat
for warmth instead of for growth.
During the rewarming process, the hypothermic infant should be observed for hypotension
as vasodilation occurs. Volume expanders may be
needed to maintain an adequate blood pressure.
Apnea and seizures may occur as a result of hypoxia
or decreased cerebral blood flow after vasodilation.
Hypothermia as a strategy to minimize adverse outcomes from hypoxic-ischemic encephalopathy continues to be the focus of considerable research to
determine safety and efficacy (see Chapter 26).
HYPERTHERMIA
The hyperthermic infant may feel warm to touch,
and skin color may be ruddy as the infant attempts
to increase heat loss by vasodilation. Sweating
may occur in a term infant but generally is not
present in infants of less than 36 weeks gestational age. Sweating may first appear on the forehead,
followed by the chest, upper arms, and lower body.
Hyperthermia is manifested by irritability, lethargy,
hypotonia, apnea, a weak or absent cry, or poor feeding. Tachypnea or tachycardia may be seen as the infant
attempts to increase heat loss.
Infants with thermal instability should be closely watched for changes in behavior, feeding patterns, and respiratory status. Temperatures should
be monitored frequently in any infant exhibiting
these symptoms or who feels cool or warm to
touch. Early recognition of thermal instability may
prevent further consequences and possibly permanent
injury or death (Box 6.10).
Treatment and Intervention
The usual approach to treating the hyperthermic
infant is to cool by removing external heat sources
BOX
6.10
Critical assessment findings for hyperthermia are as follows:
• Reddened skin that is warm to touch
• Tachypnea
• Tachycardia
• Irritability, lethargy, hypotonia, weak cry
• Poor feeding
• Apnea
• Sweating in more mature babies
• Dehydration
CRITICAL FINDINGS
HYPERTHERMIA
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and by removing anything that blocks heat loss.
The most common causes of hyperthermia in
intensive care nurseries are iatrogenic. Check the
heating controls for proper function and thermistors for proper position. Consider other sources of heat (e.g., direct sunlight, heaters, lights)
as possible causes of hyperthermia. Excessive
bundling with blankets and a hat and elevated
environmental temperature can cause a newborn’s body temperature to rise into the febrile
range. When evaluating the treatment options
in the hyperthermic infant, one should consider
removing extra blankets or swaddling materials.
Nonenvironmental causes of hyperthermia (e.g.,
infection, dehydration, CNS disorders) should be
considered. During the cooling process, skin, axillary, and environmental temperatures should be
monitored and recorded every 30 minutes.
Complications
Recognizing late preterm and term neonates who
meet the criteria for neonatal cooling for HIE (see
Chapter 26, Box 26.7) and preventing hyperther-
mia is critical to decreasing morbidity and mortality.
Outcomes of asphyxiated newborn infants who did
not receive cooling in the NICHD Neonatal Research
Network whole body cooling trial were studied at 18
to 22 months72 and at 6 to 7 years.70 Within the first
72 hours of life, asphyxiated newborns without cooling
exhibited elevated temperatures that were associated
with a four-fold increase in death or moderate disability.72 Follow-up of this cohort to ages 6.7 years found
that the association between their elevated temperatures and death or IQ less than 70 persisted.
Vasodilation to increase heat loss may cause hypo-
tension and dehydration as a result of increased IWL.
Seizures and apnea may also occur as a result
of high core temperature. Fluid status should be
monitored by assessing intake, output, electrolytes,
serum and urine osmolality, skin turgor, and mucous
membranes. Fluids should be adjusted to account
for IWL. Blood pressure should be assessed to
detect hypotension, and volume expanders should be
administered as needed.
Cardiorespiratory monitoring to detect apnea
should be used. Ventilation may be needed if apnea
persists or is unresponsive to stimulation. Subtle signs
of seizures may include facial grimacing, nystagmus,
tremors, apnea, opisthotonos posturing, tongue thrusting, or staring (see Chapter 26).
70
PARENT/CAREGIVER TEACHING
While the neonate is in the NICU, parents should be
taught the importance of maintaining the newborn’s
normal body temperature. Temperature should be
taken before parents touch the infant through the
portholes of the incubator or hold their infant. While
the infant is outside the incubator, monitor the
skin temperature continuously with a telethermometer. Unwrapping the infant to check the tem-
perature exposes him or her to cold stress. Additional
heat sources (e.g., radiant warmer, hat, extra blankets)
may be needed while parents hold the infant. Teach
parents to monitor their infant’s temperature and to
notify the nurse if it rises or falls (Box 6.11).
Before discharge, teach parents to take an accurate axillary temperature and to notify their physician if it drops below 36°C (96.8°F) or rises above
37.8°C (100°F).4 A parent should not routinely
take a rectal temperature. The temperature should
be taken whenever the infant feels cool or warm to the
touch. The nurse should observe the parents taking the
infant’s axillary temperature before discharge.
The home environment should be kept at a
temperature that prevents heat and cold stress. A
room temperature that is comfortable for the parent
usually is suitable for the infant. The infant should
be in clothing appropriate for the room temperature. For example, if the parent requires a sweater to
BOX
6.11
• Teach parents how to take an axillary temperature on their newborn
• Teach parents how to dress their infant with clothes and blankets
• Teach parents appropriate safety precautions, which include verbal
• Teach parents to notify their infant’s primary health care provider im-
PARENT/CAREGIVER TEACHING
TEMPERATURE REGULATION
and maintain the axillary temperature between 36.5°C and 37.4°C
(97.7°F and 99.3°F).
and use an appropriate environmental temperature to maintain the
baby’s temperature in the above range.
and written information about recognizing signs and symptoms of
a sick/ill infant, as well as how the infant acts, including temperatures either higher than or, more commonly, lower than the range of
36.5°C to 37.4°C (97.7°F to 99.3°F).
mediately or to take the infant to the nearest emergency department
for temperatures out of the above range, especially if the baby’s
feeding pattern changes.
5
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161
be comfortable, the infant probably also requires a
sweater. Parents often overdress the infant or overheat the home, and this may cause hyperthermia.
Parents should be given written instructions before
discharge on how and when to take an axillary
temperature, when to call the physician, and how
to maintain a comfortable environment for their
infant.
REFERENCES
1. Adamkin D, Carlo W, Dreyer G, et al. Thermoregulation. In.
Neonatal Clinical Management Guidelines. 5th ed. Upper Saddle
River, NJ: Paradigm Health; 2007.
2. Agren J, Sjors G, Sedin G. Ambient humidity influences the
rate of skin barrier maturation in extremely preterm infants. J
Pediatr. 2006;148(5):613–617.
3. Altimier L. Thermoregulation: what’s new? What’s not? New-
born Infant Nurs Rev. 2012;12:51.
4. American Academy of Pediatrics; American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 8th ed.
Elk Grove Village, IL: The Academy; 2017.
5. Anderson GC, Lane AE, Chang H. Axillary temperature in
transitional infants before and after tub bath. Appl Nurs Res.
1995;8(3):123.
6. Andrews C, Whatley C, Smith M, et al. Quality-improvement
effort to reduce hypothermia among high-risk infants on a
mother-infant unit. Pediatrics. 2018;141(3):e20171214.
7. Backes CH, Huang H, Iams JD, et al. Timing of umbilical cord
clamping among infants born at 22 through 27 weeks’ gestation. J Perinatol. 2016;36(1):35.
8. Barone G, Corsella M, Papacci P, et al. Feasibility of transferring intensive cared preterm infants from incubator to open
crib at 1600 grams. Ital J Pediatr. 2014;40:41.
9. Berger I, Marom R, Mimouni F, et al. Weight at weaning of
preterm infants from incubator to bassinet: a randomized controlled trial. Am J Perinatol. 2014;31(6):535.
10. Bergman N, Linley LL, Fawcus SR. Randomized controlled
trial of skin-to-skin contact from birth versus conventional
incubator for physiological stabilization in 1200–2199 gram
newborns. Acta Paediatr. 2004;93(6):779.
11. Bergstrom A, Okong P, Ransjo-Arvidson AB. Immediate maternal thermal response to skin-to-skin care of newborn. Acta
Paediatr. 2007;96(5):655.
12. Billimoria Z, Chawla S, Bajaj M, et al. Improving admission
temperature in extremely low birth weight infants: a hospital-based multi-intervention quality improvement project. J
Perinat Med. 2013;41(4):455.
13. Billner-Garcia R, Spilker A, Goyal D. Skin-to-skin contact:
newborn temperature stability in the operating room. MCN
Am J Matern Child Nurs. 43(3):158.
14. Blackburn S, DePaul D, Loan LA, et al. Neonatal thermal care,
part III: the effect of infant position and temperature probe
placement. Neonatal Netw. 2001;20(3):25.
15. Boyd H, Brand MC, Hagan J. Care of 500 to 1500 gram
premature infants in hybrid incubator. Adv Neonatal Care.
2017;17(5):381.
16. Brogan J, Rapkin G. Implementing evidence-based neonatal
skin care with parent-performed delayed immersion baths.
Nursing Women’s Health. 2017;21(6):442.
17. Bryanton J, Walsh D, Barrett M, et al. Tub bathing versus traditional sponge bathing for the newborn. J Obstet Gynecol Neonat
Nurs. 2004;33(6):704–712.
18. Caka SY, Gosen D. Effects of swaddled and traditional tub bathing methods on crying and physiologic responses of newborns.
J Spec Pediatr Nurs. 2018;23(1). https://doi:10.111/jspn.12202.
19. Caldas JPS, Millen FC, Camargo JF, et al. Effectiveness of a quality measure program to prevent admission hypothermia in very
low-birth weight preterm infants. J Pediatr. 2018;84(4):368.
20. Cardona-Torres LM, Amador-Licona N, Garcia-Campos ML,
Guizar-Mendoza JM. Polyethylene wrap for thermoregulation in the preterm infant: a randomized trial. Indian Pediatr.
2012;49(2):129.
21. Carns J, Kawaza K, Quin MK, et al. Impact of hypothermia on
implementation of CPCP for neonatal respiratory distress syndrome in a low-resource setting. PLoS One. 2018;13(3):e0194144.
22. Castrodale V, Rinehart S. The golden hour: improving the
stabilization of the very low birth-weight infant. Adv Neonatal
Care. 2014;14(1):9.
23. Chang HY, Sung YH, Wang SM, et al. Short-and long-term
outcomes in very low birth weight infants with admission
hypothermia. PLoS One. 2015;10(7):e0131976.
24. Charpak N, Ruiz JG, Zupan J, et al. Kangaroo mother-care: 25
years after. Acta Paediatr. 2005;94(5):514.
25. Cole J, Brissette N, Lundari B. Tub baths or sponge baths for
newborn infants? Mother Baby J. 1999;4:39.
26. Colwell A. To bathe or not to bathe: the neonatal question.
Neonatal Netw. 2015;32(4):216.
27. Conde-Agudelo A, Diaz-Rossello JL. Kangaroo mother care
to reduce morbidity and mortality in low birthweight infants.
Cochrane Database Syst Rev. 2016;8:CD002771.
28. Cone Jr TE. History of the Care and Feeding of the Premature
Infant. Boston, MA: Little. Brown; 1985.
29. Datta V, Saili A, Goel S, et al. Reducing hypothermia in newborns admitted to a neonatal care unit in a large academic hospital in New Delhi, India. BMJ Open Quality. 2017;6(2):e000183.
30. DeAlmeida MF, Guinsburg R, Sancho GA, et al. Hypothermia and early neonatal mortality in preterm infants. J Pediatr.
2014;164(2):271.
31. DeGorre C, Decima P, Degrugilliers L, et al. A mean body
temperature of 37 degrees C for incubated preterm infants is
associated with lower energy costs in the first 11 days of life.
Acta Paediatr. 2015;104(6):581.
32. DeGuines C, Degrugilliers L, Ghyselen L, et al. Impact of nursing care on the temperature environment in preterm newborns
in closed convective incubators. Acta Paediatr. 2013;102(3):e96.
33. Delanaud S, Decima P, Pelletier A, et al. Additional double-wall
roof in single-wall, closed, convective incubators: impact on
body heat loss from premature infants and optimal adjustment
of the incubator air temperature. Med Eng Phys. 2016;38(9):922.
34. Doglioni N, Cavallin F, Mardegan V, et al. Total body polyethylene wraps for preventing hypothermia in preterm infants: a
randomized trial. J Pediatr. 2014;165(2):261.
35. Dollberg S, Rimon A, Atherton HD, Hoath SB. Continuous
measurement of core body temperature in preterm infants. Am
J Perinatol. 2000;17(5):257.
36. Dollberg S, Mimouni FB, Weintraub V. Energy expenditure
in infants weaned from a convective incubator. Am J Perinatal.
2004;21(5):253–256.
37. Don Paul JM, Perkins EJ, Pereira-Fantini PM, et al. Surgery and
magnetic resonance imaging increase the risk of hypothermia
in infants. J Paediatr Child Health. 2018;54(4):426.
UNIT TWO Support of the Neonate162
https://t.me/medicina_free
38. Duran R, Vatansever U, Acunas B, Sut N. Comparison of
temporal artery, mid-forehead skin and axillary temperature
recordings in preterm infants <1500 g of birthweight. J Paediatr
Child Health. 2009;45(7-8):444.
39. Duryea EL, Nelson DB, Wyckoff MH, et al. The impact of
ambient operating room temperature on neonatal and maternal
hypothermia and associated morbidities: a randomized controlled trial. Am J Obstet Gynecol. 2016;214(4):505.
40. Edraki M, Paran M, Montaser i S, et al. Compar ing the effects
of swaddled bathing methods on body temperature and crying
duration in preterm infants: a randomized clinical trial. J Caring
Sci. 2014;3(2):83.
41. Engle WA, Tomashek KM and the Committee on Fetus and
Newborn of the American Academy of Pediatrics. “Latepreterm” infants: a population at risk. Pediatrics. 2007;120(6):1390.
42. Engorn BM, Kahntroff SL, Frank KM, et al. Perioperative hypothermia in neonatal intensive care unit patients: effectiveness
of a thermoregulation intervention and associated risk factors.
Paediatr Anaesth. 2017;27(2):196.
43. Fenton C, McNinch NL, Bieda A, et al. Clinical outcomes in
preterm infants following institution of delayed cord clamping
practice change. Adv Neonatal Nurs. 2018;18(3):223.
44. Flenady VJ, Woodgate PG. Radiant warmers versus incubators
for regulating body temperature in newborn infants. Cochrane
Database Syst Rev. 2003;4:CD000435.
45. Friedrichs J, Staffileno BA, Fogg L, et al. Axillary temperatures in
full-term newborn infants. Adv Neonatal Care. 2013;13(5):361.
46. Gaylord MS, Wr ight K, Lorch K, et al. Improved fluid management utilizing humidified incubators in extremely low birth
weight infants. J Perinatal. 2001;21(7):438.
47. Godfrey K, Nativio D, Bender CV, Schlenk EA. Occlusive
bags to prevent hypothermia in premature infants: a quality
improvement initiative. Adv Neonatal Care. 2013;13(5):311.
48. Gouchon S, Gregori D, Picotto A, et al. Skin-to-skin contact
after cesarean delivery: an experimental study. Nurs Res.
2010;59(2):78.
49. Greenspan JS, Cullen AB, Touch SM, et al. Thermal stability
and transition studies with a hybrid warming device in neonates. J Perinatol. 2001;21(3):167.
50. Haddad L, Smith S, Phillips KD, Heidel RE. Comparison of
temporal artery and axillary temperatures in healthy newborns.
J Obstet Gynecol Neonatal Nurs. 2012;41(3):383.
51. Handhayanti L, Rustina Y, Budiati T. Differences in temperature changes in premature infants during invasive procedures
in incubators and radiant warmers. Compl Child Adolesc Nurs.
2017;40(suppl 1):102.
52. Harer M, Vergales B, Cady T, et al. Implementation of a
multidisciplinary guideline improves preterm infant admission
temperatures. J Perinatol. 2017;37(11):1242.
53. Henningsson A, Nystrom B, Tunnel R. Bathing or washing
babies after birth. Lancet. 1981;19(8260-61):1401.
54. Hsu KH, Chaing MC, Lin SW, et al. Thermal blanket to
improve thermoregulation in preterm infants: a randomized
controlled trial. Pediatr Crit Care Med. 2015;16(7):637.
55. Hu XJ, Wang L, Zheng RY, et al. Using polyethylene plastic
bag to prevent hypothermia in very low birth weight infants: a
randomized controlled trial. J Perinatol. 2018;38(4):332.
56. Hylen A, Karlsson E, Svatberg L, et al. Hygiene for the newborn: to bathe or to wash? J Hyg. 1981;91:529.
57. Ibrahim CP, Yoxall CW. Use of plastic bags to prevent hypothermia at birth in premature infants: do they work at lower
gestations? Acta Paediatr. 2009;98:256.
58. Ibrahim CP, Yoxall CW. Use of self-heating gel mattresses
eliminates admission hypothermia in infants born below 28
weeks’ gestation. Eur J Pediatr. 2010;169(2):795.
59. Jensen CF, Ebbesen F, Petersen JP, et al. Hypothermia at
neonatal intenisive care unit admission was not associated with
respiratory disease or death in very preterm infants. Epub ahead
of print. Acta Paediatr. 2017;106(12):1934.
60. Jia YS, Lin ZL, Lv H, et al. Effect of delivery room temperature
on the admission temperature of premature infants: a randomized controlled trial. J Perinatol. 2013;33(4):264.
61. Johannsen JKI, Vochem M, Neuberger P. Does a higher ambient
temperature in the delivery room prevent hypothermia in preterm
infants < 1500 grams? Z Geburtshilfe Neonatal. 2017;221(5):235.
62. Karlsson V, Heinemann AB, Sjors G, et al. Early skin-to-skin
care in extremely preterm infants: thermal balance and care
environment. J Pediatr. 2012;161(3):422.
63. Kim SM, Lee EY, Chen J, Ringer SA. Improved care and
growth outcomes by using hybrid humidified incubators in
very preterm infants. Pediatrics. 2010;125(1):e137.
64. Knobel RB, Wimmer JE, Holbert D. Heat loss prevention for
preterm infants in the delivery room. J Perinatol. 2005;25(8):304.
65. Knobel RB, Vohra S, Lehman CU. Heat loss prevention in the
delivery room for preterm infants: a national survey of newborn intensive care units. J Perinatol. 2005;25(5):514.
66. Knobel R, Holditch-Davis D. Thermoregulation and heat loss
prevention after birth and during neonatal intensive care unit
stabilization of extremely low birth weight infants. J Obstet
Gynecol Neonatal Nurs. 2007;36(3):280.
67. Knobel-Dail RB, Holditch-Davis D, Sloane R, Guenther BD,
Katz LM. Body temperature in premature infants during the
first week of life: exploration using infrared thermal imaging. J
Therm Biol. 2017;69:118.
68. Lantz B, Ottosson C. Using axillary temperature to approximate rectal temperature in newborns. Acta Paedaitr.
2015;104(8):766.
69. Laptook AR, Bell EF, Shankaran S, et al. and the Generic and
Moderate Preterm Subcommittee of the NICHD Neonatal
Research Network. Admission temperature and associated
mortality and morbidity among moderately and extremely
preterm infants. J Pediatr. 2018;192:53.
70. Laptook AR, McDonald SA, Shankaran S, et al. Elevated temperature and 6-to-7 year outcome of neonatal encephalopathy.
Ann Neurol. 2013;73:520.
71. Laptook AR, Salhab W, Baskar B. Admission temperature of
low birth weight infants: predictors and associated morbidities.
Pediatrics. 2007;119:6643.
72. Laptook AR, Tyson J, Shankaran S, et al. Elevated temperatures
after hypoxic-ischemic encephalopathy: risk factor for adverse
outcomes. Pediatrics. 2008;122(4):491.
73. Leadford AE, Warren JB, Manasyan A, et al. Plastic bags for the
prevention of hypothermia in preterm and low birth weight
infants. Pediatrics. 2013;132(1):e128.
74. Lee G, Flannery-Bergey D, Randall-Rollins K, et al. Accuracy
of temporal artery thermometry in neonatal intensive care
infants. Adv Neonatal Care. 2011;11(1):62.
75. L’Herault J, Petroff L, Jaffrey J. The effectiveness of a thermal
mattress in stabilizing and maintaining body temperature
during the transport of very low birth weight newborns. Appl
Nurs Res. 2001;14(4):210.
76. Lewis DA, Sanders LP, Brockopp DY. The effect of three
nursing interventions on thermoregulation in low birth weight
infants. Neonatal Netw. 2011;30(3):160.
CHAPTER 6 Heat Balance
https://t.me/medicina_free
163
77. Lewis LA, Jacobson AF. Electronic health record documentation
of nursing care procedures and change in weight of healthy,
moderately premature neonates. Neonatal Netw. 2017;36(6):348.
78. Li S, Guo P, Zou Q, et al. Efficacy and safety of plastic wrap
for prevention of hypothermia after birth and during NICU
in preterm infants: a systematic review and meta-analysis. PLoS
One. 2016;11(6):e0156960.
79. Liley HG, Mildenhall L, Morley P, and the Australian and New
Zealand Committee on Resuscitation. Neonatal Resuscitation
Guidelines 2016. J Paediatr Child Health. 2017;53(7):621.
80. Loring C, Gregory K, Gargan B, et al. Tub bathing improves
thermoregulation of the late preterm infant. J Obstet Gynecol
Neonatal Nurs. 2012;41(2):171.
81. Ludington-Hoe SM, Lewis T, Morgan K, et al. Breast and
infant temperatures with twins during shared kangaroo care. J
Obstet Gynecol Neonatal Nurs. 2006;35:223.
82. Ludington-Hoe SM, Morgan K, Abouelfettoh A. A clinical guideline
for implementation of kangaroo care with premature infants of 30
or more weeks’ postmenstrual age. Adv Neonatal Care. 2008;8(2):S3.
83. Lyu Y, Shah PS, Ye X Y, et al. Association between admission
temperature and mortality and major morbidity in preterm
infants born at fewer than 33 weeks’ gestation. JAMA Pediatr.
2015;169(4):e150277.
84. Maastrup R, Greisen G. Extremely preterm infants tolerate
skin-to-skin contact during the first weeks of life. Acta Paedaitr.
2010;99(8):1145.
85. Maayan-Metzger A, Yosipovitch G, Hadad E, et al. Effect of
radiant warmer on transepidermal water loss (TEWL) and skin
hydration in preterm infants. J Perinatol. 2004;24(6):372.
86. Magzub N, Salama H, Albaridi A, Zeed MA, Thampan J. Hu midity levels inside newborn incubators used in the neonatal
intensive care unit (NICU). Neonatology Today. 2016;11(1):1.
87. Mank A, VanZanten HA, Meyer MP, et al. Hypothermia in
preterm infants in the first hours after birth: occurrence, course
and risk factors. PLoS One. 2016;11(11):e0164817.
88. McCall EM, Alderdice F, Halliday HL, et al. Interventions to
prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev. 2010;3:CD004210.
89. McCarthy LK, Molloy EJ, Twomey AR, et al. A randomized
trial of exothermic mattresses for preterm newborns in polyethylene bags. Pediatrics. 2013;132(1):e135.
90. McGrory L, Owen LS, Thio M, et al. A randomized trial of
conditioned or unconditioned gases for stabilizing preterm
infants at birth. J Pediatr. 2018;193:47.
91. Medoff-Cooper B, Holditch-Davis D, Verklan MT, et al. Newborn clinical outcomes of the AWHONN late preterm infant
research-based practice project. J Obstet Gynecol Neonatal Nurs.
2012;41(6):774.
92. Mellien A. Incubators versus mothers’ arms: body temperature
conservation in very-low-birth-weight premature infants. J
Obstet Gynecol Neonatal Nurs. 2001;30(2):157.
93. Meyer MP. Swaddling and heat loss. Arch Dis Child Fetal Neo-
natal Ed. 2003;88(3):F256.
94. Meyer MP, Hon D, Ishrar N, et al. Initial respiratory support
with cold, dry gas versus heated humidified gas and admission
temperature in preterm infants. J Pediatr. 2015;166(2):245.
95. Miller SS, Lee HC, Gould JB. Hypothermia in very low birth
weight infants: distribution, risk factors and outcomes. J Perina-
tol. 2011;31(suppl 1):S49.
96. Molgat-Seon Y, Daboval T, Chou S, Jay O. Assessing neonatal
heat balance and physiologic strain in newborn infants nursed
under radiant warmers in intensive care with fentanyl sedation.
Eur J Appl Physiol. 2014;114(12):2539.
97. Moore E, Bergman N, Anderson GC, Medley N. Early skinto-skin contact for mothers and their healthy newborn infants.
Cochrane Database Syst Rev. 2016;11:CD003519.
98. Morassutti FR, Cavallin F, Zaramella MD, et al. Association of
rewarming rate on neonatal outcomes in extremely low birth
weight infants with hypothermia. J Pediatr. 2015;167(3):557.
99. Morehouse D, Williams L, Lloyd C, et al. Perioperative hypothermia in NICU infants: its occurrence and impact on infant
outcomes. Adv Meonatal Nurs. 2014;14(3):153.
100. Mori R, Khanna R, Pledge D, Nakayama T. Meta-analysis of
physiological effects of skin-to-skin contact for newborns and
mothers. Pediatr Int. 2010;52(2):161.
101. Motil KJ, Blackburn MG, Pleasure JR, et al. The effects of
four different radiant warmer temperature set-points used for
rewarming neonates. J Pediatr. 1974;84(4):546.
102. Narendran V, Hoath SB. Thermal management of the low
birth weight infant: a cornerstone of neonatology. J Pediatr.
1999;134(5):529.
103. New K, Flenady V, Davies MW. Transfer of preterm infants
from incubators to open cot at lower versus higher body
weight. Cochrane Database Syst Rev. 2011;9:CD004214.
104. New K, Flint A, Bogossian F, East C, Davies MW. Transferring
preterm infants from incubators to open cots at 1600 grams: a
multicenter randomized controlled trial. Arch Dis Child Fetal
Neonatal Ed. 2012;97(2):F88.
105. Newton T, Watkinson M. Preventing hypothermia at birth in
preterm babies: at a cost of overheating some? Arch Dis Child
Fetal Neonatal Ed. 2003;88(3):F256.
106. Nimbalkar SM, Patel VK, Patel DV, et al. Effect of early skinto-skin contact following delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial. J
Perinatol. 2016;34(5):279.
107. O’brien EA, Colaizy TT, Brumbaugh JE, et al. Body temperature of the very low birth weight infants on admission
to a neonatal intensive care unit. J Matern Fetal Neonatal Med.
2019;32(16):2763.
108. Olsen K, Koch M. Bundle them up for transport—a quality
improvement initiative. Air Medical J. 2016;35(5):279.
109. Park HK, Choi BS, Lee SJ, et al. Practical application of kangaroo mother care in preterm infants: clinical characteristics and
safety of kangaroo mother care. J Perinatal Med. 2014;42(2):239.
110. Philip AG. The evolution of neonatology. Pediatr Res.
2005;58(4):799.
111. Pinheiro JM, Furdon SA, Boynton S, et al. Decreasing hypothermia during delivery room stabilization of preterm neonates.
Pediatrics. 2014;133(1):e218.
112. Pinheiro JM, Boynton S, Furdon SA, et al. Use of chemical
warming packs during resuscitation is associated with decreased
rates of hypothermia in very low-birth-weight neonates. Adv
Neonatal Care. 2011;11(5):357.
113. Reilly MC, Vohra S, Rac VE, et al. The Vermont Oxford
Network Heat Loss Prevention (HeLP) Tr ial Study group.
Randomized trial of occlusive wrap for heat loss in preterm
infants. J Pediatr. 2015;166(2):262–268.e2.
114. Sarman I, Can G, Tunell R. Providing warmth for preterm
babies by a heated water filled mattress. Arch Dis Child. 1989;64
(1 Spec No):29.
115. Schafer D, Boogaart S, Johnson L, et al. Comparison of neonatal skin sensor temperatures with axillary temperature. Adv
Neonatal Care. 2014;14(1):52.
116. Shafie H, Syed Zakaria SZ, Adlie A, et al. Polyethylene versus
cotton cap as an adjunct to body wrap and cotton cap. Pediatr
Int. 2017;59(7):776.
UNIT TWO Support of the Neonate164
https://t.me/medicina_free
117. Sheldon B. An encapsulated history of thermoregulation in the
neonate. Neo Rev. 2004;5:78.
118. Silverman W, Sinclair J, Agate F. The oxygen cost of minor
changes in heat balance of small newborn infants. Acta Paediatr
Scand. 1966;55(3):294.
119. Silverman W, Agate F. Variation in cold resistance among small
newborn animals. Biol Neonate. 1964;6:113.
120. Simon P, Dunnaway D, Bright B, et al. Thermal defense of
extremely low gestational age newborns during resuscitation: exothermic mattresses vs polyethylene wrap. J Perinatol. 2011;31(1):33.
121. Sinclair JC. Servo-control for maintaining abdominal skin temperature at 36° C in low birth weight infants. Cochrane Database
Syst Rev. 2002;1:CD001074.
122. Singh A, Duckett J, Newton T, Watkinson M. Improving
neonatal unit admission temperatures in preterm babies: exothermic mattresses, polyethylene bags or traditional approach? J
Perinatol. 2010;30(1):45.
123. Smith J, Alcock G, Usher K. Temperature measurement in the
preterm and term neonate: a review of the literature. Neonatal
Netw. 2013;32(1):16.
124. Smith J, Usher K, Alcock G, Buettner P. Application of plastic wrap
to improve temperatures in infants born less than 30 weeks’ gestation: a randomized controlled trial. Neonatal Netw. 2013;32(4):235.
125. Syrkin-Nikolau ME, Johnson KJ, Colaizy TT, et al. Temporal
artery temperature measurement in the neonate. Am J Perinatol.
2017;34(10):1026.
126. Thomas KA. Comparability of infant abdominal skin and
axillary temperatures. Newborn Infant Nurs Rev. 2003;3:173.
127. Thomas KA, Magbalot A, Shinabarger K, et al. Seasonal
mapping of NICU temperature. Adv Neonatal Care. 2010;10 (5
suppl):83.
128. Toubas PL, Nelson R. The role of the French midwives in
establishing the first special care units for sick newborns. J
Perinatal. 2002;22(1):75.
129. Trevisanuto D, Coretti I, Doglioni N, et al. Effective temperature under radiant warmer: does the device make a difference?
Resuscitation. 2011;82(6):720.
130. Valizadeh L, Mahallei M, Safaiyan A, Ghorbani F, Peyghami M.
Comparison of the effect of plastic cover and blanket on body
temperature of preterm infants hospitalized in NICU: randomized controlled trial. J Caring Sci. 2017;6(2):163.
131. Van der Spek RDG, van Lingen RA, van Zoeren-Grobben D.
Body temperature measurement in VLBW infants by continuous
skin measurement is a good oe even better alternative than
continuous rectal measurement. Acta Paediatr. 2009;98(2):282.
132. Watkinson M. Temperature control of premature infants in the
delivery room. Clin Perinatol. 2006;33(1):43.
133. Wilson E, Maier RF, Norman M, et al. Admission hypothermia
in very preterm infants and neonatal mortality and morbidity. J
Pediatr. 2016;175:61.
134. Wilson E, Zeitlin J, Piedvache A, et al. Cohort study from 11
European countries highlighted differences in the use and
efficacy of hypothermia prevention strategies after very preterm
birth. Epub ahead of print. Acta Paedaitr. 2018;107(6):958.
135. World Health Organization. Thermal Protection of the Newborn: A
Practical Guide; 1997. https://www.who.int/maternal_child_ad-
olescent/documents/ws42097th/en/. Accessed July 22, 2019.
136. YIP WY, Quek BH, Fong MCW, et al. A quality improvement
project to reduce hypothermia in preterm infants on admission
to the neonatal intensive care unit. Int J Qual Health Care.
2017;29(7):922.
137. Zecca E, Corsello M, Priolo F, et al. Early weaning from
incubator and early discharge of preterm infants: randomized
clinical trial. Pediatrics. 2010;126(3):e651.
138. Zeitlin J, Manktelow BN, Piedvache A, Cuttini M, Boyle E,
et al. Use of evidence-based practices to improve survival without severe morbidity for very preterm infants: results from the
EPICE population based cohort. BMJ. 2016;354:i2976.
RESOURCES FOR PROFESSIONALS
Bissinger RL. Teaching toolbox: method for wrapping the infant in
occlusive wrap at birth. Adv Neonatal Care. 2010;10(5):239A.
Charpak N, Ruiz J.G. Latin American clinical epidemiology network
series-paper 9: the kangaroo mother care method: from scientific
evidence generated in Columbia to worldwide practice. J Clin
Epidemiol. 2017;86:125.
Gardner SL. Clinical Practice Tool: NO Rectal Temperatures in the
Newborn Infant: Evidence-Based Nursing Practice (C); 2019. Available
at: www.professionaloutreachconsultation.org or at 303-332-4291.
Purnamasari MD, Rustina Y, Waluyanti FT. Heat loss prevention
education aids nurses’ knowledge in prevention of hypothermia in
newborns. Compr Child Adolesc Nurs. 2017;40(suppl 1):37.
Raffel D. The Strange Case of Dr. Couney: How a Mysterious European
Showman Saved Thousands of American Babies. New York: Blue Rider
Press; 2018.
PHYSIOLOGIC
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7
ignificant advances in the management of
the ill preterm infants have been made in the
S
past 70 years. The clinical usefulness of the
umbilical vein was first demonstrated by Diamond
in 1947 to perform an exchange transfusion to
prevent kernicterus. Later, James used the umbilical
artery for acid-base determination. In most neonatal
intensive care units (NICU), use of these catheters
has become the standard of care to assess blood
gases, measure arterial and central venous pressures,
administer medications and fluids, and obtain laboratory samples. The development of small, indwelling, peripherally inserted central catheters provides
a route for administering the aforementioned items
and may be used for laboratory sample withdrawal
if no other method of obtaining blood is available.
The frequency and clinical significance of complications and alternatives to these intravascular routes
have been vigorously sought. The development of
noninvasive physiologic monitoring devices has
been a major step toward this goal. In addition, the
use of point-of-care testing for various laboratory
values is evolving in neonatal care. This chapter
reviews the procedures and advances in physiologic
monitoring.
MONITORING
KRISTI COE, WANDA T. BRADSHAW, AND DAVID T. TANAKA
PHYSIOLOGY
Pulmonary Physiology
Gas exchange takes place in the alveoli of the
lung. Ventilation is the movement of air into and
out of these airspaces. Diffusion is the movement
of oxygen (O2) from the alveolar space into the
pulmonary capillary and the movement of carbon
dioxide (CO2) from the pulmonary capillary into
the alveolar space for eventual exhalation. Pulmonary
perfusion is the flow of blood through the pulmonary capillaries that surround the alveolar spaces.
Once oxygen diffuses through the cells lining the
alveoli and into the capillaries, it is predominately bound to hemoglobin within the red blood
cell. Oxygen content in the arterial blood is the sum
of the amount of oxygen dissolved in the plasma and
the amount bound to hemoglobin. Approximately
3% of the oxygen content is dissolved in the
plasma, with the remaining 97% bound to
hemoglobin. PaO2 is the partial pressure of the
oxygen dissolved in arterial plasma. Fetal hemoglobin
has a higher affinity for oxygen than does adult
hemoglobin; therefore, at any given PaO2, more
oxygen is bound to fetal hemoglobin (Fig. 7.1).
Each hemoglobin molecule can carry four oxygen molecules. Oxygen saturation (SaO2) is the
percentage of oxygen bound to hemoglobin.
Carbon dioxide content in arterial blood is
the sum of the amount of carbon dioxide in the
plasma plus the amount bound to hemoglobin. As
hemoglobin gives up oxygen to the tissues, it is able
to pick up carbon dioxide. Each reduced hemoglo-
bin molecule can carry four carbon dioxide molecules, thus lowering the free hydrogen ion (H+)
concentration. Approximately 10% of the carbon
dioxide content is gas dissolved in the plasma (CO2),
60% is carbonic acid (H2CO3), and the remaining
30% is attached to proteins, predominantly hemoglobin. PaCO2 is the partial pressure of carbon
dioxide dissolved in arterial blood. It is a measured
value that denotes the partial pressure of arterial carbon dioxide. Carbon dioxide values fluctuate as
needed to maintain the hydrogen ion concentration, or pH, within a normal range. Carbon diox-
ide combines reversibly with water to yield hydrogen
(H+) and bicarbonate (HCO
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO
–
) ions. The formula is
3
–
.
3
BLUE type highlights content that is particularly applicable to clinical settings.
165
% O
Hgb saturation
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166 UNIT TWO Support of the Neonate
0
Fetal Hgb
Adult Hgb
20 40
60 80 100
PO
(mm Hg)
2
100
80
60
2
40
20
0
FIGURE 7.1 Oxygen dissociation curves for fetal hemoglobin (Hgb) (left)
and adult hemoglobin (right).
NONINVASIVE MONITORING
Use of noninvasive technologies to monitor all
neonates in the NICU is the standard of care.
Many neonates also require invasive monitoring
devices.
Oxygen and Carbon Dioxide
OXYGEN
Noninvasive monitoring of oxygenation can be
accomplished by using three monitoring technologies, pulse oximetry, transcutaneous oxygen monitoring, and
near-infrared spectroscopy. Oxygen saturation monitoring
is the most common and widely used method
for assessing oxygenation status. Transmission tech-
nology relies on a pulsating arterial vascular bed
between a dual light source and a photoreceptor.
As blood passes between the light source and the
photoreceptor, different amounts of red and infrared light are absorbed, depending on the amount
of oxyhemoglobin and reduced hemoglobin. With
reflectance oximetry, the emitter and receptor are
located beside each other. Emitted light is reflected back to the photoreceptor. This method uses
the core body to obtain oxygen saturation and is
useful when the patient’s peripheral blood flow is
diminished. With this method, the difference in
light absorption is electronically processed and
displayed by the monitor as the percentage of
arterial hemoglobin oxygen saturation expressed
as SpO2. Pulse oximetry probes are easy to
apply and require no warm-up period, calibration, or application of heat.
The second method of noninvasive monitor-
ing of oxygenation is transcutaneous oxygen tension,
which relies on the principle of oxygen diffusing
from the skin capillaries through the dermis to
the surface of the skin. To measure oxygen diffu-
sion, it is necessary to have adequate perfusion of
the site, to intermittently calibrate the sensor, and to
heat the skin, which then dilates the local capillaries
and arterializes the capillary bed, as well as promotes
faster diffusion of the oxygen from the skin.
36
Near-infrared spectroscopy (NIRS) is a newer
method of noninvasive oxygenation measurement in the NICU. NIRS was launched in 1977 to
assess cerebral oxygenation and perfusion during cardiac and neurosurgery, but its use has been expanded
into neonates, initially used peri- and postoperatively
for cardiac surgery.46 This technology is based on
tissue transparency to light in the 700- to 1000-nm
wavelength, referred to as the near-infrared spectrum.
Through a light-emitting diode (LED), NIRS releases two wavelengths of near-infrared light signals to
maximize separation of the absorbed spectra among
oxyhemoglobin and deoxyhemoglobin. The NIRS
probe also contains two optodes to receive the scattered light, one from peripheral tissue and another
from peripheral and deep tissues. After the peripheral
value is subtracted from the other value, a tissue-specific regional oxygen saturation (RSO2) value from
a 1- to 2-cm depth is attained. In comparison with
earlier technology, NIRS signifies tissue oxygen
supply and utilization, while oxygen saturation
monitoring suggests (arterial) oxygen supply to
tissues. While NIRS was initially used to assess cere-
bral oxygenation and demand by placing the adhesive
probe horizontally across the forehead, use has been
expanded to deeper organs including the kidneys
and intestines because of a superficial location in this
age group.
CARBON DIOXIDE
46
Carbon dioxide also can be assessed using two
different devices, transcutaneous carbon dioxide and
end-tidal carbon dioxide monitors. Transcutaneous car-
bon dioxide (PtcCO2) monitoring works under
similar principles as for transcutaneous oxygen
monitoring.34 The probe is a glass pH electrode
CHAPTER 7 Physiologic Monitoring
AB
CO
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167
2
38 mm Hg
C
0
FIGURE 7.2 Variations in the content of carbon dioxide during phases of
the respiratory cycle. A, End of inspiration. B, Beginning of exhalation. C, End of
mixed gases washout (dead space and alveolar gases). D, End of expiration of
alveolar gases. E, Inspiration.
D
E
that detects changes in pH caused by CO2. Heating
of the probe enhances CO2 diffusion, providing a
better correlation between the probe value and the
PaCO2 value. The second method used to measure
the content of the carbon dioxide in the respiratory
gases during the respiratory cycle is end-tidal carbon
dioxide (PetCO2) monitoring, also called capnometry.
With capnometry, an infrared light absorption
determines the amount of CO2 present in the
sample. Capnography provides a visual graphic
curve of PetCO2. The carbon dioxide content
varies widely with the phase of the respiratory cycle.
During inspiration, there are minimal amounts of
carbon dioxide, whereas at the end of expiration,
the carbon dioxide values are at their maximum
level (Fig. 7.2). Until recently, the relatively fast
respiratory rate of newborns, combined with the
small tidal volumes, resulted in inaccurate values
when measured by end-tidal carbon dioxide monitors. Advances in technology have improved the
reliability of this monitoring technique for newborn infants.
COMBINED OXYGEN–CARBON DIOXIDE
MONITORING
SpO2/PtcCO2 sensors combining pulse oximetry
and transcutaneous carbon dioxide monitoring
have been developed. The heated sensor is attached
to the patient’s ear. It provides rapid SpO2 values
followed by carbon dioxide information within
minutes as the site is warmed and arterialized.
A single probe, designed to withstand motion
artifact and low perfusion states, leads from the
patient to the monitor. The probe is attached to
the ear, thus its removal for chest radiographs or
prone positioning is not necessary. Studies on
normal adults, infants, and very-low-birth-weight
(VLBW) infants have shown acceptable correlation
with both invasive and noninvasive monitoring
techniques for oxygen. Carbon dioxide values
were less reliable but allowed trending of ventilation status.
38
Amplitude Integrated
Electroencephalography
Although the gold standard for monitoring cerebral
activity in neonates is continuous electroencephalography (cEEG), a tool that is complementary, amplitude-integrated electroencephalography (aEEG),
is now used in many NICUs. Infants appropriate
for use of aEEG may include those with clinically evident seizure activity or those with seizure
activity who have experienced a perinatal hypoxic
event.38 Feasibility is likely improved with aEEG
because this technology requires only four electrodes
compared with many more channels needed for
cEEG. Like other complementary tools, aEEG
provides trends over time that allow clinicians to view
and assess for abnormal cerebral activity allowing for
prompt treatment.
38
Cardiorespiratory Monitoring
The electrical activity of an infant’s heart is picked
up by chest leads (usually three) placed on the
infant and recorded by a cardiorespiratory monitor.
The recording is displayed on a visual screen as the
infant’s electrocardiographic pattern. The infant’s
respiratory pattern also is recorded, because the
chest leads electronically detect movement of the
chest with each respiration.
Blood Pressure Monitoring
Systolic blood pressure, measured in millimeters of
mercury (mm Hg), is the pressure at the height
of the arterial pulse and coincides with left
ventricular systole. Diastolic blood pressure, also
measured in mm Hg, is the lowest point of the
arterial pulse and coincides with left ventricular
diastole. Pulse pressure is the difference between
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the systolic and diastolic blood pressure. Mean
arterial pressure is the diastolic pressure plus one-
third of the pulse pressure. Central venous pressure
is the pressure in the right atrium and may be
approximated by the blood pressure (volume) in
any of the large central veins.
Point-of-Care Testing
Point-of-care testing (POCT) involves testing
performed at or near the patient rather than in
a laboratory. This process has steadily evolved from
crude blood glucose determinations to numerous
types of monitoring. Currently, whole-blood glucose values, transcutaneous bilirubin, fecal occult
blood, gastric pH, urine dipstick, activated clotting
time, hematocrit, some electrolyte values, and arterial blood gases are part of POCT for the neonatal
population.
DATA COLLECTION
The indications for using the various techniques for
physiologic data collection depend on the infant’s
clinical situation.
Noninvasive Oxygen and Carbon
Dioxide Monitoring
Oxygen monitoring is indicated in infants
receiving oxygen for any reason (see Chapter
23). Acute monitoring is used as a part of
the management of acute respiratory disorders.
Long-term monitoring is used to wean infants
with chronic lung disease from oxygen therapy.
Noninvasive oxygen monitoring is useful during
transport, in emergency situations, and during
procedures. However, this method provides no
information on hemoglobin level, adequacy of
ventilation, and oxygen delivery to the tissues and
should be used as one part of total oxygenation
and ventilation assessment. Despite how oxygen
saturation monitoring is used more, less variability in oxygen tension has been demonstrated
when transcutaneous oxygen monitoring has
been employed.
Carbon dioxide monitoring is useful for verifying that the endotracheal tube is in the trachea
(end-tidal CO2 monitoring) and for the infant with
a respiratory disease in whom retention of carbon
36
dioxide may become clinically significant (end-tidal
CO2 and transcutaneous CO2 monitoring).
Cardiorespiratory Monitoring
Cardiorespiratory monitoring should be used in
all infants who require intensive or intermediate
care, as well as in all infants at risk for apnea or
rhythm disturbances.
Blood Pressure Monitoring
Blood pressure monitoring should be used in
the infant requiring surgery, in the acutely ill
infant with cardiorespiratory distress, and in
any other illness in which hypotension may be
a significant contributor to the pathologic state.
Central venous pressure should be monitored in
infants who may experience an excess or loss of
blood volume.
Umbilical Artery Catheters
An umbilical artery catheter (UAC) is placed in
those infants requiring frequent arterial blood
gas determinations, continuous monitoring of
arterial blood pressure, and infusion of parenteral fluids. The practice of medication adminis-
tration through a UAC varies, although there are
no published data in the past decade regarding this
practice.
ing catheters include critically ill neonates and
those with congenital heart disease or disorders that
cause respiratory insufficiency (e.g., surfactant deficiency, meconium aspiration syndrome, persistent
pulmonary hypertension, diaphragmatic hernia).
Although use of an indwelling UAC allows
arterial pressure monitoring and accessibility for
parenteral infusions, it is generally not used for
these indications alone.
31,45
Infants who are candidates for indwell-
Umbilical Vein Catheters
Umbilical vein catheters (UVCs) are useful for
exchange transfusions, central venous pressure
monitoring, emergency administration of fluids
or chemicals in delivery room resuscitation,
and administration of parenteral fluids and
medications in the NICU, as well as obtaining
blood for laboratory analysis. UVCs are used
with increasing frequency for initial management
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