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What are the indications for airway clearance?
- - Retained secretions:
- Atelectasis
- RDS
- BPD
- Intubation
- Ineffective cough
- Pain
- Paralysis
- Neuromuscular disease
- - Excessive secretions:
- Cystic fibrosis
- Pneumonia
- Asthma
- Broncholitis
- Bronchiectasis
- - Aspiration:
- Meconium
- Foreign body
- - Prophylaxis:
- Post-extubation
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What are the contra-indication for airway clearance?
- Pulmonary hemorrhage
- Hypoxemia during treatment
- Feedings within the previous 45-60 minutes
- History of reflux
- History of intraventricular hemorrhage
- Untreated pneumothorax
- Congestive heart failure
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What is the indication for suctioning?
To facilitate the removal of respiratory tract secretions
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What are the hazards of suctioning?
- Bradycardia.
- - Vagal nerve stimulation.
- - Hypoxemia induced.
- Hypoxemia.
- Mucosal damage.
- Atelectasis.
- Airway contamination
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What is the procedure for suctioning a neonatal patient, including catheter size?
- Suction catheter should be no larger than half the size of the inner diameter of the endotracheal tube.
- - Table 6-5 pg. 167
- Suction vacuum should be set at negative 60-80 for infants.
- - Negative 80-100 for pediatric patient
- Limit to less than 5 seconds of suction.
- Saline irrigation needs to be limited to 0.5 ml of normal saline.
- Pre-oxygenate at 10-15% higher FI02 unless patient has problems, then increase as needed.
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What is Postural drainage?
Placing the patient in the correct gravity dependent position to let gravity pull the secretion up toward larger airways
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What is Percussion?
- Rhythmic clapping on the chest to get the vibration to loosen secretions from the airways.
- Done while the patient is in gravity dependent position, this will facilitate secretion removal
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What is Vibration?
A rapid movement of the chest wall to shake loose secretions
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What is PEP?
- A resistance device is used to create positive expiratory pressure as the patient breathes in and out through via mask or mouthpiece.
- May (or may not) be given in conjunction with aerosol therapy.
- The expiratory resistance is performed 10-20 times followed by forced exhalation technique to expel secretions.
- The expiratory resistance causes mechanical bronchodilation and increases the ventilation of areas distal to the mucous obstructions.
- Forced exhalations then propel mucous up and our of the airway.
- Use as many repeated attempts as needed to remove mucous.
- As the patient exhales resistance is adjustable to 15-30 or as high as 60-80 cm H2O
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What is forced expiratory technique (FET)?
- After performing PEP therapy, the patient should perform a
- forced expiratory maneuver (Huff Cough).
- - Patient inhales slowly then does 2-3 "huff" exhalations against an open glottis followed by a strong cough.
- - The "huffs" help to stabilize and keep the airways open, allowing secretions to mobilize in the airways.
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What is the Flutter Valve?
- Action: Loosens mucus through expiratory oscillation as positive expiratory pressure splints airways
- Used independently
- Technique dependent
- Portable
- May not be effective at low airflows
- Time required: 10 - 15 minutes
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What is the Vest?
Generally, you will start with the pressure control dial at #1 and increase, as tolerated.
- Setting the frequency for CF patients.
- Low freq. 5-10 Hz for 10 min.
- Medium freq. 11-15 Hz for 10 min.
- High freq. 16-20 Hz for 10 min
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What are some facts about Intrapulmonary Percussive Ventilation (IPV)?
- Used independently or with caregiver supervision
- Used with aerosolized meds
- Technique dependent
- May not be well tolerated by patient
- Action: "percussion" on both inspiration, but most benficial on expiration
- Rate 120-300 cycles/min (2 - 5 Hz).
- Pressures of 10-40 cm H2O
- Nebulizer produces dense, small particle aerosol
- Time required: 20 minutes
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In theory, three forms of therapy are provided during IPV:
- 1. percussive oscillatory vibrations which loosen retained secretions.
- 2. high density aerosol delivery to hydrate viscous mucous plugs
- 3. positive expiratory pressure (PEP) to recruit alveolar lung units and assist in expiratory flow acceleration during a cough maneuver.
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What is an In-Exsufflator?
- Action: creates mechanical "cough" through the use of high flows at positive and negative pressures.
- Positive/negative pressures up to 60 cm of water.
- Used independently or with caregiver assistance.
- There are five primary settings on the typical automatic in-exsufflator:
- - The inhale time.
- - The inhale pressure.
- - The exhale time.
- - The exhale pressure.
- - The pause time between the inhale and exhale phases.
- These settings are adjusted so that they generate a good, productive cough without causing discomfort.
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What are the indications for aerosol therapy?
the need to deliver an aerosol medication to the lower airways
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What are some substances we aerosolize?
- Beta adrenergic agents
- Anticholinergic agents
- Anti-inflammatory agents (Corticosteroids)
- Mediator-modifying compounds (Mast Cell Wall Stabilizers)
- Mucokinetics (Mucolytics)
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What are the hazards of aerosol therapy?
- Nosocomial infection
- Medication side effects
- Drug reconcentration
- Ventilator malfunction
- Excessive noise
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What will affect particle amount and size?
- - Depends on the type of nebulizer.
- - Jets are used often but the amount varies considerably depending on the type and brand of nebulizer used.
- - In pediatrics, like adults, much of the medication is lost during expiration.
- More drug is delivered when the volume of diluents is increased.
- When administered to intubated infants, the dosages need to be increased due to the reduced deposition.
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What will affect Particle characteristics?
- Hygroscopic nature of particles.
- Viscosity and concentration of the medication.
- Velocity the drug (due to the administration device).
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What are some affects of Airway anatomy?
- The narrower the airway, the greater the deposition.
- Neonatal airway is small to start with then add the ET tube, bronchoconstriction, and mucous.
- Whitaker believes that the amount that the amount of drug reaching the terminal airways is negligible.
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What are some affects of Ventilatory pattern on aerosol deposition?
- Best pattern is with laminar flow in a slow deep inspiration with inspiratory pause.
- This may be done on a ventilator but is near impossible with a breathing infant.
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What are advantages of nebulizers?
- Little patient coordination required
- Effective in acute respiratory distress, flow, or volume
- Ability to give either a large or small volume of aerosol
- Drug dosage and/or particle size can be modified
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What are disadvantages of nebulizers?
- Relatively expensive
- Less easily transported
- Cleaning and preparation required
- Amount of medication delivered is variable
- Provides a medium for bacterial growth.
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What are the advantages of MDI?
- Very portable
- Efficient drug delivery
- Short preparation and delivery time
- Particles resist hygroscopic growth
- Can be used on newborns/infants
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What are the disadvantages of MDI?
- Coordination difficulties.
- Limited choice of drugs and concentrations.
- Possible reaction to propellants.
- Oropharyngeal impaction.
- Foreign body aspiration.
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What are the advantages of DPI?
- Similar to MDI
- Limited hand breath coordination needed
- No propellants
- Doses easily counted
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What are the disadvantages of DPI?
- Limited number of drugs
- Possible airway irritation
- Possible reaction to the carrier powder
- Requires high inspiratory flow
- Requires loading before use
- Less useful in acute obstruction
- Can only be used on ages 4+
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What is the SPAG and what is it used for?
- Designed to deliver Ribavirin for RSV bronchiolitis
- Gas-powered jet nebulizer uses three jets
- Uses drying chamber to shrink particles
- Baffle is sides of container
- Aerosolized Ribavirin has generally fallen out of favor as a treatment for RSV.
- The exception being patients with chronic respiratory or cardiac anomalies who go on to develop RSV.
- New research is looking at Ribavirin as a possible treatment for SARS.
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What are the indications for Oxygen Therapy?
- Treat and relieve documented hypoxemia
- Decrease WOB
- Decrease workload on heart
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What are the contradications for Oxygen Therapy?
NONE!
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For Neonates less than 35 weeks gestation, what is expected PaO2 and SpO2?
- Pao2 50 - 70 mmHg
- Spo2 88 - 95%
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For Larger infants and children greater than 35 weeks gestation, what is expected PaO2 and SpO2?
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What are the signs of hypoxia in a newborn?
- Retractions
- Grunting
- Nasal flaring
- Apnea and/or bradycardia
- Cyanosis
- - Because fetal Hb has increased affinity for 02 the newborn's pa02 may drop to 30-40 torr before cyanosis appears
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What are the hazards of Oxygen Therapy in a new born?
- ROP
- Oxygen toxicity
- Cerebral vasoconstriction
- Fire hazard
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What is the GOAL of Oxygen Therapy in a newborn?
- Maintain pa02 of 50-80 torr based on the age of the newborn
- Pa02 of pa02 of 100 torr may be required for PPHN (persistent pulmonary hypertension in the newborn)
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What are common Oxygen Delivery Devices for neonatal and pediatric patients?
- Oxygen Hood
- Oxygen Cannula
- Mist Tent
- Oxygen Mask
- Resuscitation Bag
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What is an Oxygen Hood and when are they used?
- delivery device of choice in the preemie for the first days of life.
- The oxygen is administered via a heated humidified hood via a blender.
- - Both the fi02 and the air temperature must be controlled.
- - An O2 analyzer should always be used.
- Increased CO2 build up if the flow is too low is a potential hazard
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What is an Oxygen Cannula and when are they used?
- Newborns, even preemies can be given 02 by nasal cannula.
- USED ON PATIENT with chronic oxygen needs or as weaning tool from other modes of delivery.
- Because the infant's Ve is so low, the FI02 at a given flow rate differs drastically from the FI02 of adult 02 cannula.
- Neonatal flow meters can be calibrated as low as 0.025 lpm.
- Estimated FIO2 on the nasal cannula at various flowrates for patients under two years of age:
- 1/4 Lpm 25%
- 1/2 Lpm 30%
- 1 lpm 35%
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What is a Mist Text and when are they used, and what is the disadvantage of it?
- RARELY USED ANYMORE
- Once the infant is old enough to roll over and sit up, he is too big for a O2 hood.
- The disadvantage of a mist tent is that the infant will no longer get an exact fi02 inside the croup tent.
- The fi02 of the mist tent runs between 21% and 50%, but there is little control because the enclosure is too large for fine-tuning.
- Mist tents are more tolerated by the infant, since mom can get in tent to hold them
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What is an Oxygen Mask, when are they used, and is it a good choice for oxygen delivery device?
- The 02 mask is a poor choice for an infant because it can obstruct his/her airway.
- It is a poor choice for the toddler because the child has an instinct to protect his/her face and nose and he/she will pull it off.
- At about 3 years of age the child might wear a mask, but the nasal cannula is generally preferred.
- Once a child is old enough to tolerate a mask, one has the same choices as with the adult.
- As with the adult patient the entrainment mask is the only sure method of exact fi02 delivery because these are high flow systems.
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What are the indications for Resuscitation bag?
- Delivery of oxygen for short periods.
- Delivery of oxygen during initial resuscitation.
- FIO2 80-100% when used properly with reservoir.
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What is thermoregulation?
The maintenance of equality between the heat dissipation and heat production from the body.
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What is themal neutral zone?
When the infant is neither gaining nor loosing heat and the oxygen consumption is its lowest, then balance is achieved.
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What is desired Rectal and Skin Temperature?
- rectal temperature at 36.5-37.5
- skin temperature 36-36.5
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What is Internal Thermal Gradient, and what is it regulated by?
- The difference in temperature between the warm core of the body and the cool skin
- - Regulated by:
- The metabolic rate.
- The amount of subcutaneous fat.
- The body surface area.
- The distance from the body core to the skin surface
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What is non shivering thermogenesis?
increased heat production due to burning of brown fat
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Why do preemies have a difficult time regulating ITG (Internal Thermal Gradient)?
- A large amount of skin surface to body weight.
- Relatively thin layers of skin.
- Low amounts of body fat.
- A high metabolic rate and rarely get enough calories to keep them warm
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What are the 4 types of heat loss that concerns us in the NICU?
- Radiant
- Conductive
- Convective
- Evaporative
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What is Radiant heat loss?
Dissipation of heat to surrounding objects not in direct contact with them
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What is Conductive heat loss?
Transfer of heat to cooler surfaces in contact with the infant like wet blankets or cold stethoscope.
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What is Convective heat loss?
Loss of heat from the skin to surrounding air. Air currents carry away warm blanket of air around them
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What is Evaporative heat loss?
As liquids (urine, sweat) evaporate, they carry away heat
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What is Hypothermia in a newborn referred to as and hazards of it?
- - Cold Stress:
- The initial response to cold stress is vasoconstriction to shunt away from the skin.
- - This leads to:
- Anaerobic metabolism in shunted areas causing metabolic acidosis.
- Pulmonary vasoconstriction and worsens the hypoxemia and acidosis but altering the V/Q ratio.
- Hypoxemia, further worsening the response to hypothermia
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___________ also triggers nonshivering thermogenesis and fat metabolism to produce heat resulting in further acidosis and hypoglycemia. All of these factors will keep the infant warm for a while. If the cold stress if corrected, the neonate may recover with no harm
Hypothermia
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___________ produces initial vasodilation to dissipate heat and is soon followed by increased metabolism and oxygen consumption
Hyperthermia
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What cause Hyperthermia?
- Infection.
- Dehydration.
- Malfunctioning incubator.
- Radiant warmer.
- Humidifier.
- Phototherapy lights
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What is Insensible Water Loss?
- Extra cellular fluid makes up 45% of body weight of a term infant vs. 60% of a 32 week infant.
- This means that the more premature the infant, the more they are prone to insensible water loss
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What are some factors the cause Insensible Water Loss?
- Increased motor activity.
- Skin break down.
- Respiratory distress.
- Fever.
- Phototherapy.
- Congenital skin defects.
- Environmental temperature.
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What is an Isolette?
An Isolette (incubator) is an environmental containment chambers that contains the neonate in a controlled temperature, humidity, and oxygen.
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What are the Advantages and Disadvantages of an Isolette?
- They are easy to operate but hard to control due to frequent opening.
- The neonate is not readily accessible inside the plastic case.
- If the incubator can be left closed they work well and maintain temperature without undue increases in room temperature
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What is a Radiant Warmer?
Radiant (i.e. open) warmers make the neonate more accessible.
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What are the Advantages an Disadvatages of Radiant Warmers?
- They are usually servo controlled to maintain the core temperature of the neonate.
- However, the neonate is openly exposed to the environment.
- Core temperatures of the maintained easily, but cold stress still may occur because the inability to control the environment
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What are the effects of Overstimulation of a newborn?
- Sensory overload from the noise, light, and activities of the NICU provide too much stimulation to the eyes, ears, and brain of the neonate.
- This can interfere with both the development and organization of the central nervous system
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What is behavioral-based care?
- Handling only when the behavioral and physiological sign indicate.
- Behavioral-based care seeks provide basic care during times of non-stress:
- - In theory, this will reduce overstimulation
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What can cause Skin Trauma to a newborn, and what are the risks of it?
- Because the skin is so thin, removing tape, excessive handling, and other such activities may tear the skin.
- This causes the break down the first barrier of their defense system.
- This leaves the premature infant much more susceptible to infection.
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How do we reduce the risks of Skin Trauma to a newborn?
- Use mild soaps applied with cotton ball when cleaning.
- Use ETT holders as opposed to taping.
- Appropriate placement and relocation of devices like transcutaneous monitors.
- Using elastic wraps rather than tape to hold pulse oximeter sensors in place.
- Use of transparent IV dressings.
- Increasing the infant's environmental humidity.
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What are the different electrolytes that concern us and what do they do?
- Sodium - water balance
- Potassium - acid-base balance and hydrogen diffusion (both are positively charged)
- Calcium - integral for heart function and bone integrity
- Magnesium - necessary for calcium regulation
- Chloride - anion gap and Hamburger phenomenon
- Phosphate - essential in energy metabolism
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Review Table 7-5 on slide 25.
Do it? Eright good.
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What is Jaundice (Hyperbilirubanemia) and facts about it?
- Jaundice is the yellow-orange skin color associated with abnormal levels of biliruban.
- Most biliruban comes from the breakdown of old red blood cells.
- It is common in neonates.
- 25 to 50% of all term infants.
- Higher percentage in premies.
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What causes an increase in biliruban (jaundice)?
- The higher percentage of red blood cells.
- The shorter life span of red blood cells.
- The inability of the neonatal liver to conjugate the excess biliruban.
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What are compications associated with Jaundice?
- Encephalopathy is the most serious complication associated with pathologic jaundice.
- This is because the fat from the unconjugated biliruban crosses the blood-brain and attaches itself to the brain cells.
- Hyperbilirubanemia, untreated can then lead to permanent brain damage and developmental delay.
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How do you treat Jaundice?
- Phototherapy (mostly used), where blue light causes the biliruban to decompose into water-soluble particles with are excreted by the kidneys.
- Phenobarbital, increases conjugation.
- Exchange transfusion, replacing the effected RBC's.
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What is Necrotizing Enterocolitis (NEC) characterized by?
- NEC is characterized by ischemia and necrosis of the intestines.
- Untreated it may lead to abdominal distention, perforation, sepsis, and maybe death
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What is Necrotizing Enterocolitis (NEC) associated with?
- Necrotizing entercolitis (NEC) is an idiopathic disorder associated with:
- - Mucosal wall injury.
- - Bacterial invasion of the damaged area.
- - Formula feeding.
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What is Necrotizing Enterocolitis (NEC)?
Break down and destruction of a portion of the intestines
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What are Clinical signs of Necrotizing Enterocolitis (NEC)?
- Blood in the stool.
- Bile tinged vomiting.
- Abdominal distention.
- Pneumatosis on x-ray (abnormal presence of air)
- General signs of sepsis.
- Poorly tolerated feeding.
- Lethargy.
- Increased O2 requirements. (pressure pushes on lungs cause smaller Vt)
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What is the Treatment for Necrotizing Enterocolitis (NEC)?
- Prevention is the best treatment.
- Good hand washing technique.
- Stop feedings.
- NG suctioning to remove bile residue.
- Frequent abdominal x-rays.
- Surgical intervention to repair perforated or necrotic intestines.
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