acade mNyews Contributing Editors: Debbie Fraser, MN, RNC-NIC; Heather Goodall, MSN, RNC-NIC, IBCLC; Arlene Lovejoy-Bluem, MS, RNP, CNS, RNC-NIC, C-NPT, RRT; Jody Ridky, RN, MA; Kathryn Rudd, RNC-NIC, C-NPT, MSN; Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC
The Academy of Neonatal Nursing Honors All Neonatal Nurses on September 15th, National Neonatal Nurses Day
News from ANN’s Executive Committee AnnMarie Barber, MS, MSN, CRNP Throughout the course of our careers, we have the ability to work within the various facets of health care delivery, whether it is in a clinical role, administrative position, or as an educator. We may find ourselves functioning in more than one of these roles at any given time. During my 27-year career in nursing, I have been fortunate to have participated in many of the opportunities the profession has to offer. Through my experience as a staff nurse, nurse manager, and NNP, I know firsthand the value of having these choices. I have come to the realization that, regardless of the area in which a nurse may choose to practice, certain components of clinician, manager, and educator may exist regardless of the official title we hold. The role of educator in particular stands out as a constant thread across the continuum of nursing responsibilities regardless of the area of the profession in which one chooses to dedicate her career. Nursing education both in terms of academic training and continuing professional development is the foundation upon which we develop our identity as a profession. Education not only expands our knowledge but also ensures that we maintain accountability for our clinical practice. The Academy of Neonatal Nursing has been c ommitted to providing nurses in the specialty of newborn health comprehensive and diverse educational programs. Throughout the many stages of my career, I have greatly benefited from ANN’s dedication to quality neonatal education. What I found to be most valuable was the various methods that the Academy offers to enhance my professional growth and meet my educational needs. Just as I have moved forward
within the profession, ANN has also expanded its approach to providing educational opportunities such as online access to past and present issues of Neonatal Network, webinars, and Baby ANN, just to name a few. In my current position as a Clinical Nurse Educator (CNE) in the pharmaceutical industry, I have had the opportunity to visit many NICUs throughout the Northeast region of the country. I have met wonderful neonatal clinicians who have shared with me the nuances of their clinical practice as well as their endeavors to provide and participate in continuing education. These experiences influenced my decision to pursue membership on ANN’s Executive Committee. As a new committee member, my hope is to share my unique perspective regarding the educational needs and accomplishments of the nurses I encounter as well as to facilitate the utilization of the varied educational modalities available to ANN members. In addition to the numerous educational tools made available to neonatal nurses through the Academy, there also exist extraordinary opportunities to share knowledge with other clinicians by means of journal articles, poster abstracts, and podium presentations. I have seen exceptional ideas and programs instituted in many NICUs that deserve notice within our specialized community. I feel very fortunate to be able to combine my role as a regional CNE with my role as an ANN Executive Committee member by encouraging neonatal nurses to share their successes through the Academy’s wide-ranging opportunities. It is vital to the Disclosure The views and opinions expressed in the News of the Academy of Neonatal Nursing are those of the contributing editors and do not necessarily reflect those of the Academy of Neonatal Nursing. The Academy of Neonatal Nursing is not responsible for products, programs, or links mentioned in these pages. They are provided as a convenience and should not be viewed, in any way, as an endorsement of any particular website, company, product, or service.
ACADEMY NEWS VOL. 33, NO. 5, SEPTEMBER/OCTOBER 2014 © 2014 Academy of Neonatal Nursing 295 http://dx.doi.org/10.1891/0730-0832.33.5.295
profession that nurses remain aware of how much they can inspire each other through all methods of education. The Executive Committee’s commitment to neonatal nursing education exemplifies the concept of information exchange, advancement of professional development, and clinical excellence. I am very grateful to be a member of such a dedicated group of neonatal nursing professionals, and I look forward to contributing to the advancement of the Academy’s important mission.
SAVE THE DATE! 12th Annual Advanced Practice Neonatal Nurses Conference March 11–14, 2015 Sheraton Chicago Hotel & Towers Now accepting Poster and Podium Abstracts. Deadline is January 9, 2015. More information available at www.academyonline.org
Member in the Spotlight—Pat Johnson
Debbie Fraser, MN, RNC-NIC Meet ANN member Pat Johnson, DNP, MPH, RN, NNP, who is one of neonatal nursing’s true pioneers. A member of ANN since its inception, Pat has been instrumental in the development of the neonatal nurse practitioner role in North America. In 1973, Pat piloted the first NNP role as part of her MSN program. She published the results of her thesis in 1976, comparing a group of patients she managed with those managed by pediatric residents. Each group had similar outcomes and quality of care as measured by a blinded review done by neonatologists. Despite the positive results of this study, organized medicine and nursing did not have a favorable review of the NNP role and didn’t consider it equivalent to roles in primary care. A manpower shortage in the 1970s resulted in acceptance of the NNP role by neonatologists, but Pat experienced ongoing resistance from nurses who thought that the NNP role amounted to nurses practicing medicine. During this time, Pat worked as an endowed neonatal nursing educator but continued to hone her skills as an NP by doing follow-up clinics and some neonatal transports. In 1976, Pat was recruited by St. Paul
Children’s Hospital in Minnesota to form a neonatal nurse clinician/practitioner team and published an article on the evaluation of that team. In the 1980s, the NNP role became more widely recognized and gained nursing acceptance, and Pat moved to the University of Arizona Colleges of Nursing and Medicine to manage an internship program for graduating NNPs. During that time, Pat was a member of the AAP Fetus and Newborn Committee and a charter member of the National Association of Neonatal Nurses. She was president of NANN from 1992 to 1994. In the 1990s, the NNP role evolved from a procedural role to more holistic care, especially for those babies that required attention to detail. To this day, Pat sees this as a place for NNPs to shine. Pat has been active in ANN since the beginning of the organization, playing a key role in the first executive committee and, more recently, represented ANN members as our representative on the American Nurses Association Membership Assembly, while also serving as a member of the Congress of Nursing Practice and Economics. Pat has been a long-standing reviewer for Neonatal Network and is currently the editor of the Pharmacology column. She was instrumental in the establishment of the Foundation of Neonatal Research and Education and has served as its president since 2000. When asked about the changes that she has seen over her career, Pat offered the following: “When I started in the 1970s, the mortality rate for 34-week infants was 30 percent, and now we are offering care to 23-week infants.” Pat identifies the incorporation of evidence in practice as neonatal nursing’s greatest achievement and says this was the motivating factor for her to return to school in 2008 to obtain her DNP. Pat continues to practice as an NNP in Phoenix and tells me that she loves her work! “I could work seven days a week; that’s how passionate I feel about the role of an NNP.” Pat sees a strong future for neonatal nursing and the NNP role but feels that we need to focus on providing quality education programs with an adequate grounding in practice in order to develop the strongest clinicians. In her words, “Clinical practice is integral to incorporating didactic knowledge into evidence-based practice.” Pat Johnson embodies the true spirit of ANN members—commitment to excellence in practice!
Practice Questions for Certification Kathryn Rudd, RNC-NIC, C-NPT, MSN In keeping with ANN’s mission to advance the knowledge and education of neonatal nurses, we would like to challenge and prepare you for your certification exam with Practice Questions for Certification. If you have study topics or questions you would like to contribute, please contact Ute Berman at [email protected]. The answers to these questions are on page 299.
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1. The risk of a pneumothorax is increased in newborns with a history of: a. apnea b. hypoxia c. meconium 2. The presence of which of the following is more likely in an infant with suspected neonatal encephalopathy? a. Babinski reflex b. corneal reflex c. tongue fasciculation 3. Which of the following features of congenital diaphragmatic hernia increases pulmonary vascular resistance? a. increased pulmonary blood flow b. decreased pulmonary vascular resistance c. pulmonary hypoplasia
It has been demonstrated that MTCT of HIV can be prevented; it is almost totally avoided in high-income countries.1 Prevention of MTCT (PMTCT) depends on adequate and convenient health care services as well as trained health care providers. While research has provided evidence needed for policies and guidelines related to PMTCT, it has not been shown that the information is being adequately disseminated and implemented in low-income, resource-limited countries with the greatest incidence of HIV and AIDS. Global and national guidelines for PMTCT of HIV, formulated using research-based studies, are in place; yet, there is very little research involving the application of the guidelines in the clinical setting in a resource-limited country. Yolanda Ogbolu, PhD, CRNP-Neonatal, conducted a research study of current PMTCT practices in 27 public health facilities in Nigeria. Ninety percent of the global burden of HIV is in sub-Saharan Africa, 30 percent in Nigeria alone.2 The results of her study are revealing and lead to a better understanding of which policies are not being implemented and why. Fewer than half of the nurses in the study had received PMTCT training. Those who were trained were the older, more experienced nurses, with labor and delivery nurses having the most training and postpartum nurses having the least. Nurses with PMTCT training had significantly higher practice scores, revealing an increased application of PMTCT practices. Most nurses in the study were aware of lab studies, used gloves, and recognized the need for antiretroviral therapy (ART) for newborns. Still, 27 percent would not treat the intrapartum mothers with ART. Surprisingly, contrary to the evidence-based guidelines and policies, most nurses reported they would not
International Neonatal News Nursing Research in Nigeria Jody Ridky, RN, MA As reported in the UNAIDS Global Report, in 2011 approximately 330,000 children ,15 years of age became infected with HIV, and approximately 230,000 children died from AIDS. The vast majority of these infections were from mother-to-child transmission (MTCT) in sub-Saharan Africa.1
Mechanical Ventilation—Word Search Debbie Fraser, MN, RNC-NIC L
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Directions: Here are 12 words that relate to the topic of Mechanical Ventilation. See if you can find them all. Words may appear horizontally, vertically, diagonally, or even backwards. The solution to this word search puzzle will be published in the Nov/Dec 2014 News of the Academy.
airleak alveoli breath CPAP compliance hypoplasia lung peep pip pressure pulmonary volume
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bathe HIV-exposed infants soon after birth, and 85.5 percent would not recommend breastfeeding. Due to multiple factors, which exist in the low income, resource-limited countries, including poverty, the increased morbidity and mortality associated with inability to purchase formula, as well as mixed feeding (combining breastfeeding with formula feeding), breastfeeding of HIV-exposed infants can be recommended in many situations.2 Nurses comprise 60 percent of the health care workforce in sub-Saharan Africa; they are the primary medical care providers for HIV- and AIDS-positive mothers in resource-limited countries. In this study, several issues related to the translation of evidence-based practice guidelines for PMTCT of HIV into practice were identified. Access to care and gaps in knowledge and performance of nurses affect the outcomes for the infants born to HIVpositive mothers. The access issue is being addressed in Nigeria with the decentralization of HIV care from tertiary centers to primary centers. Nurses in the primary and secondary settings must receive additional PMTCT education; they need to see the advantage of the new evidence and recognize that it is an improvement over current practices before they will change. The new practice must be compatible with both existing practices and the needs of the patients. Keeping the new practices simple and well defined will increase the likelihood of implementation. As with all new practices, the nurses should have an opportunity to trial the new practice and observe results from the changes. Clinical leaders should demonstrate the evidencebased new practices in the clinical settings where they can be observed by the staff. Many strategies are discussed to address the gaps in knowledge and problems with the implementation of the evidence-based practices. Educators, clinical leaders, and policymakers can use the findings and recommendations made to improve training programs and create ways to ensure the translation of research into practice. 1. AVERT–AVERTing HIV and AIDS. Preventing mother-to-child transmission of HIV. http://www.avert.org/preventing-mother-childtransmission-hiv.htm. Accessed June 24, 2014. 2. Ogbolu Y, Iwu EN, Zhu S, Johnson JV. Translating research into practice in low-resource countries: progress in prevention of maternal to child transmission of HIV in Nigeria. Nurs Res Pract. 2013;2013:848567. http://dx.doi.org/10.1155/2013/848567. Accessed July 28, 2014.
Medication Highlight Dexmedetomidine Hydrochloride Use in the NICU Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC Dexmedetomidine hydrochloride (Precedex, Hospira Inc., Lake Forest, IL), was approved by the U.S. Food and Drug Administration in 1999 initially for the sedation of intubated and mechanically ventilated adults up
to 24 hours.1 Since then, it has also been investigated for the short-term sedation of intubated and mechanically ventilated infants and children, prevention of emergence delirium after general anesthesia, sedation during noninvasive radiologic procedures, management of withdrawal after prolonged use of opioids and benzodiazepines, during extubation and postextubation, and for procedural sedation.2–4 It appears to be effective and well tolerated in preterm and full-term neonates.5 It can be used for nonintubated patients prior to and/or during surgical and other procedures.4 Dexmedetomidine hydrochloride has sedative, analgesic, and anesthetic qualities. It is a selective alpha 2 adrenergic receptor agonist of the imidazole subclass, similar in structure to clonidine.1 Activation of these receptors in the locus coeruleus results in sedation and anxiolysis.1 Because of its short half-life of 2–3 hours,1–2 dexmedetomidine is given parenterally by continuous slow infusion not to exceed 24 hours.4 The half-life is 6 minutes.2 Metabolism is by direct glucuronidation in the liver via the cytochrome P450 2A6 pathway. There is minimal excretion of unchanged drug in the urine. Neonatal profiles appear to be different as compared with older children and adults. Neonates exhibit a longer half-life and a larger area under the concentration curve, indicating that lower doses may be required to achieve the same level of sedation and to avoid adverse effects.5 Preterm neonates have decreased plasma clearance and a longer elimination half-life than term neonates.5 Preterm and term neonates have a larger volume of distribution and increased free unbound medication as compared with adults. Lam and colleagues’ study of neonates and infants with heart disease reported that administration did not result in hemodynamic instability, and a concomitant Neonatal Abstinence Syndrome (from News of the Academy – July/August 2014 Issue)
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reduction in the dosing of opioid and benzodiazepine agents was possible.1 Precedex is supplied as a clear, colorless, isotonic solution with a pH of 4.5 to 7.0. Each mL contains 118 mcg of dexmedetomidine hydrochloride equivalent to 100 mcg (0.1mg) of dexmedetomidine and 9 mg of sodium chloride in water. The solution is preservative free and contains no additives or chemical stabilizers. It is freely soluble in water. Dosing should be individualized and titrated to the desired clinical response.4 This medication should be administered using a controlled infusion device. Loading doses reported in the literature vary from 0.5–1 mg/kg over 10 minutes, followed by an infusion of 0.1–1.5 mcg/kg/hour.1–4 Precedex should not be coadministered through the same IV catheter as blood or plasma, as compatibility has not been established. 4 Precedex is incompatible with amphotericin B and diazepam.4 Precedex is compatible with 0.9% sodium chloride in water, 5% dextrose in water, 20% mannitol, lactated Ringer’s solution, 100 mg/mL magnesium sulfate solution, and 0.3% potassium chloride solution.4 Hemodynamic effects are not significantly different from baseline in most studies reviewed.1,3,4 Lam and colleagues’ study of critically ill children with congenital heart disease reported all the patients remained hemodynamically stable during the infusion.1 There were no substantial differences in major hemodynamic variables (NIRS, MAP, respiratory rate, heart rate, CVP, inotropic score) between neonates and infants undergoing surgery, heart transplantation, or other surgical procedures. Hemodynamic stability was defined as no need to escalate inotropic support, give IV fluid boluses, or hold or decrease the dexmedetomidine dose during the infusion. In addition, there were no differences in oxygen saturation, blood pH, PaO2, PaCo2, or serum bicarbonate values before or after the infusion. There were no rhythm abnormalities, no significant abdominal signs or symptoms (vomiting or abdominal distention), no withdrawal symptoms associated with termination, and no neurologic abnormalities during the infusion or after it
was terminated. Dexmedetomidine administration significantly reduced the daily dosing of opioids and benzodiazepines in the study population. Of interest, in the study by Lam and colleagues, 74 percent of participants received clonidine after the infusion was discontinued. The need for clondine was attributed to a possible withdrawal phenomenon, as this is an increasing concern in the literature. Some authors report symptoms such as increased agitation, hypertension, tachycardia, emesis, dilated pupils, diarrhea, increased muscle tone, sneezing, and seizures with abrupt discontinuation of prolonged infusions (those lasting .96 hours).2,6–8 O’Mara and colleagues report prolonged use (19 days) in a 24-week gestational age infant experiencing severe agitation refractory to high-dose IV narcotics and benzodiazepines.4 There were no significant adverse effects directly attributed to the dexmedetomidine use. The infusion allowed weaning of mechanical ventilation with eventual extubation, as well as rapid tapering of the sedatives. These researchers recommended further study of dexmedetomidine as a first-line or adjunct therapy with narcotics for sedation of ventilated infants. Adverse effects have been reported to be predictable and dose dependent.5 Symptoms reported in adults include hypotension, bradycardia, sinus arrest, transient hypertension, dry mouth, nausea, and atrial fibrillation.4 The transient hypertension was seen primarily during the loading dose administration. There is much to learn. More studies are needed to determine if dexmedetomidine is safe and efficacious for neonates. Initial studies appear promising. 1. Lam F, Bhutto AT, Tobias JD, Gossett JM, Morales L, Gupta P. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease. Pediatr Cardiol. 2012;33:1069-1077. doi 10.1007/s00246-012-0227-6 2. Hummel P. Use of dexmedetomidine hydrochloride for sedation in the NICU. NANN E-News. 3(4). http://www.nann.org/enews/July2011/feature-html. Published July, 2011. Accessed June 26, 2014. 3. Dilek O, Yasemin G, Atci M. Preliminary experience with dexmedetomidine in neonatal anesthesia. J Anaesthesiol Clin Pharmacol. 2011;27(1):17-22. 4. O’Mara K, Gal P, Ransommd J, et al. Successful use of dexmedetomidine for sedation in a 24-week gestational age neonate. Ann Pharmacother. 2009;43(10):1707-1713.
Answers to Practice Questions for Certification 1. Answer is C. In: Acute Care of at-Risk Newborns (ACoRN). Vancouver, British Columbia: ACoRN Neonatal Society; 2010:3-57. 2. Answer is C. In: Acute Care of at-Risk Newborns (ACoRN). Vancouver, British Columbia: ACoRN Neonatal Society; 2010:5-15. 3. Answer is C. In: Polin RA, & Yoder MC. Workbook in Practical Neonatology. Philadelphia, PA: Saunders Elsevier; 2007:134.
5. Pullen LC. Dexmedetomidine-effective sedative for neonates. www. medscape.com/viewarticle/818075. Published December 19, 2013. Accessed July 28, 2014. 6. Darnell C, Steiner J, Szmuk P, Sheeran P. Withdrawal from multiple sedative agent therapy in an infant: is dexmedetomidine the cause or the cure? Pediatr Crit Care Med. 2010;11(1):e1-e3. 7. Tobias JD. Dexmedetomidine: are there going to be issues with prolonged administration? J Pediatr Pharmacol Ther. 2010;15:4-9. 8. Weber MD, Thammasitboon S, Rosen DA. Acute discontinuation syndrome from dexmedetomidine after protracted use in a pediatric patient. Paediatr Anaesth. 2008;18:87-88.
ACADEMY NEWS VOL. 33, NO. 5, SEPTEMBER/OCTOBER 2014299
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The Academy of Neonatal Nursing Honors All Neonatal Nurses on September 15th, National Neonatal Nurses Day
News from ANN’s Executive Committee AnnMarie Barber, MS, MSN, CRNP Throughout the course of our careers, we have the ability to work within the various facets of health care delivery, whether it is in a clinical role, administrative position, or as an educator. We may find ourselves functioning in more than one of these roles at any given time. During my 27-year career in nursing, I have been fortunate to have participated in many of the opportunities the profession has to offer. Through my experience as a staff nurse, nurse manager, and NNP, I know firsthand the value of having these choices. I have come to the realization that, regardless of the area in which a nurse may choose to practice, certain components of clinician, manager, and educator may exist regardless of the official title we hold. The role of educator in particular stands out as a constant thread across the continuum of nursing responsibilities regardless of the area of the profession in which one chooses to dedicate her career. Nursing education both in terms of academic training and continuing professional development is the foundation upon which we develop our identity as a profession. Education not only expands our knowledge but also ensures that we maintain accountability for our clinical practice. The Academy of Neonatal Nursing has been c ommitted to providing nurses in the specialty of newborn health comprehensive and diverse educational programs. Throughout the many stages of my career, I have greatly benefited from ANN’s dedication to quality neonatal education. What I found to be most valuable was the various methods that the Academy offers to enhance my professional growth and meet my educational needs. Just as I have moved forward
within the profession, ANN has also expanded its approach to providing educational opportunities such as online access to past and present issues of Neonatal Network, webinars, and Baby ANN, just to name a few. In my current position as a Clinical Nurse Educator (CNE) in the pharmaceutical industry, I have had the opportunity to visit many NICUs throughout the Northeast region of the country. I have met wonderful neonatal clinicians who have shared with me the nuances of their clinical practice as well as their endeavors to provide and participate in continuing education. These experiences influenced my decision to pursue membership on ANN’s Executive Committee. As a new committee member, my hope is to share my unique perspective regarding the educational needs and accomplishments of the nurses I encounter as well as to facilitate the utilization of the varied educational modalities available to ANN members. In addition to the numerous educational tools made available to neonatal nurses through the Academy, there also exist extraordinary opportunities to share knowledge with other clinicians by means of journal articles, poster abstracts, and podium presentations. I have seen exceptional ideas and programs instituted in many NICUs that deserve notice within our specialized community. I feel very fortunate to be able to combine my role as a regional CNE with my role as an ANN Executive Committee member by encouraging neonatal nurses to share their successes through the Academy’s wide-ranging opportunities. It is vital to the Disclosure The views and opinions expressed in the News of the Academy of Neonatal Nursing are those of the contributing editors and do not necessarily reflect those of the Academy of Neonatal Nursing. The Academy of Neonatal Nursing is not responsible for products, programs, or links mentioned in these pages. They are provided as a convenience and should not be viewed, in any way, as an endorsement of any particular website, company, product, or service.
ACADEMY NEWS VOL. 33, NO. 5, SEPTEMBER/OCTOBER 2014 © 2014 Academy of Neonatal Nursing 295 http://dx.doi.org/10.1891/0730-0832.33.5.295
profession that nurses remain aware of how much they can inspire each other through all methods of education. The Executive Committee’s commitment to neonatal nursing education exemplifies the concept of information exchange, advancement of professional development, and clinical excellence. I am very grateful to be a member of such a dedicated group of neonatal nursing professionals, and I look forward to contributing to the advancement of the Academy’s important mission.
SAVE THE DATE! 12th Annual Advanced Practice Neonatal Nurses Conference March 11–14, 2015 Sheraton Chicago Hotel & Towers Now accepting Poster and Podium Abstracts. Deadline is January 9, 2015. More information available at www.academyonline.org
Member in the Spotlight—Pat Johnson
Debbie Fraser, MN, RNC-NIC Meet ANN member Pat Johnson, DNP, MPH, RN, NNP, who is one of neonatal nursing’s true pioneers. A member of ANN since its inception, Pat has been instrumental in the development of the neonatal nurse practitioner role in North America. In 1973, Pat piloted the first NNP role as part of her MSN program. She published the results of her thesis in 1976, comparing a group of patients she managed with those managed by pediatric residents. Each group had similar outcomes and quality of care as measured by a blinded review done by neonatologists. Despite the positive results of this study, organized medicine and nursing did not have a favorable review of the NNP role and didn’t consider it equivalent to roles in primary care. A manpower shortage in the 1970s resulted in acceptance of the NNP role by neonatologists, but Pat experienced ongoing resistance from nurses who thought that the NNP role amounted to nurses practicing medicine. During this time, Pat worked as an endowed neonatal nursing educator but continued to hone her skills as an NP by doing follow-up clinics and some neonatal transports. In 1976, Pat was recruited by St. Paul
Children’s Hospital in Minnesota to form a neonatal nurse clinician/practitioner team and published an article on the evaluation of that team. In the 1980s, the NNP role became more widely recognized and gained nursing acceptance, and Pat moved to the University of Arizona Colleges of Nursing and Medicine to manage an internship program for graduating NNPs. During that time, Pat was a member of the AAP Fetus and Newborn Committee and a charter member of the National Association of Neonatal Nurses. She was president of NANN from 1992 to 1994. In the 1990s, the NNP role evolved from a procedural role to more holistic care, especially for those babies that required attention to detail. To this day, Pat sees this as a place for NNPs to shine. Pat has been active in ANN since the beginning of the organization, playing a key role in the first executive committee and, more recently, represented ANN members as our representative on the American Nurses Association Membership Assembly, while also serving as a member of the Congress of Nursing Practice and Economics. Pat has been a long-standing reviewer for Neonatal Network and is currently the editor of the Pharmacology column. She was instrumental in the establishment of the Foundation of Neonatal Research and Education and has served as its president since 2000. When asked about the changes that she has seen over her career, Pat offered the following: “When I started in the 1970s, the mortality rate for 34-week infants was 30 percent, and now we are offering care to 23-week infants.” Pat identifies the incorporation of evidence in practice as neonatal nursing’s greatest achievement and says this was the motivating factor for her to return to school in 2008 to obtain her DNP. Pat continues to practice as an NNP in Phoenix and tells me that she loves her work! “I could work seven days a week; that’s how passionate I feel about the role of an NNP.” Pat sees a strong future for neonatal nursing and the NNP role but feels that we need to focus on providing quality education programs with an adequate grounding in practice in order to develop the strongest clinicians. In her words, “Clinical practice is integral to incorporating didactic knowledge into evidence-based practice.” Pat Johnson embodies the true spirit of ANN members—commitment to excellence in practice!
Practice Questions for Certification Kathryn Rudd, RNC-NIC, C-NPT, MSN In keeping with ANN’s mission to advance the knowledge and education of neonatal nurses, we would like to challenge and prepare you for your certification exam with Practice Questions for Certification. If you have study topics or questions you would like to contribute, please contact Ute Berman at [email protected]. The answers to these questions are on page 299.
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1. The risk of a pneumothorax is increased in newborns with a history of: a. apnea b. hypoxia c. meconium 2. The presence of which of the following is more likely in an infant with suspected neonatal encephalopathy? a. Babinski reflex b. corneal reflex c. tongue fasciculation 3. Which of the following features of congenital diaphragmatic hernia increases pulmonary vascular resistance? a. increased pulmonary blood flow b. decreased pulmonary vascular resistance c. pulmonary hypoplasia
It has been demonstrated that MTCT of HIV can be prevented; it is almost totally avoided in high-income countries.1 Prevention of MTCT (PMTCT) depends on adequate and convenient health care services as well as trained health care providers. While research has provided evidence needed for policies and guidelines related to PMTCT, it has not been shown that the information is being adequately disseminated and implemented in low-income, resource-limited countries with the greatest incidence of HIV and AIDS. Global and national guidelines for PMTCT of HIV, formulated using research-based studies, are in place; yet, there is very little research involving the application of the guidelines in the clinical setting in a resource-limited country. Yolanda Ogbolu, PhD, CRNP-Neonatal, conducted a research study of current PMTCT practices in 27 public health facilities in Nigeria. Ninety percent of the global burden of HIV is in sub-Saharan Africa, 30 percent in Nigeria alone.2 The results of her study are revealing and lead to a better understanding of which policies are not being implemented and why. Fewer than half of the nurses in the study had received PMTCT training. Those who were trained were the older, more experienced nurses, with labor and delivery nurses having the most training and postpartum nurses having the least. Nurses with PMTCT training had significantly higher practice scores, revealing an increased application of PMTCT practices. Most nurses in the study were aware of lab studies, used gloves, and recognized the need for antiretroviral therapy (ART) for newborns. Still, 27 percent would not treat the intrapartum mothers with ART. Surprisingly, contrary to the evidence-based guidelines and policies, most nurses reported they would not
International Neonatal News Nursing Research in Nigeria Jody Ridky, RN, MA As reported in the UNAIDS Global Report, in 2011 approximately 330,000 children ,15 years of age became infected with HIV, and approximately 230,000 children died from AIDS. The vast majority of these infections were from mother-to-child transmission (MTCT) in sub-Saharan Africa.1
Mechanical Ventilation—Word Search Debbie Fraser, MN, RNC-NIC L
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Directions: Here are 12 words that relate to the topic of Mechanical Ventilation. See if you can find them all. Words may appear horizontally, vertically, diagonally, or even backwards. The solution to this word search puzzle will be published in the Nov/Dec 2014 News of the Academy.
airleak alveoli breath CPAP compliance hypoplasia lung peep pip pressure pulmonary volume
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bathe HIV-exposed infants soon after birth, and 85.5 percent would not recommend breastfeeding. Due to multiple factors, which exist in the low income, resource-limited countries, including poverty, the increased morbidity and mortality associated with inability to purchase formula, as well as mixed feeding (combining breastfeeding with formula feeding), breastfeeding of HIV-exposed infants can be recommended in many situations.2 Nurses comprise 60 percent of the health care workforce in sub-Saharan Africa; they are the primary medical care providers for HIV- and AIDS-positive mothers in resource-limited countries. In this study, several issues related to the translation of evidence-based practice guidelines for PMTCT of HIV into practice were identified. Access to care and gaps in knowledge and performance of nurses affect the outcomes for the infants born to HIVpositive mothers. The access issue is being addressed in Nigeria with the decentralization of HIV care from tertiary centers to primary centers. Nurses in the primary and secondary settings must receive additional PMTCT education; they need to see the advantage of the new evidence and recognize that it is an improvement over current practices before they will change. The new practice must be compatible with both existing practices and the needs of the patients. Keeping the new practices simple and well defined will increase the likelihood of implementation. As with all new practices, the nurses should have an opportunity to trial the new practice and observe results from the changes. Clinical leaders should demonstrate the evidencebased new practices in the clinical settings where they can be observed by the staff. Many strategies are discussed to address the gaps in knowledge and problems with the implementation of the evidence-based practices. Educators, clinical leaders, and policymakers can use the findings and recommendations made to improve training programs and create ways to ensure the translation of research into practice. 1. AVERT–AVERTing HIV and AIDS. Preventing mother-to-child transmission of HIV. http://www.avert.org/preventing-mother-childtransmission-hiv.htm. Accessed June 24, 2014. 2. Ogbolu Y, Iwu EN, Zhu S, Johnson JV. Translating research into practice in low-resource countries: progress in prevention of maternal to child transmission of HIV in Nigeria. Nurs Res Pract. 2013;2013:848567. http://dx.doi.org/10.1155/2013/848567. Accessed July 28, 2014.
Medication Highlight Dexmedetomidine Hydrochloride Use in the NICU Lori Williams, DNP, RNC-NIC, CCRN, NNP-BC Dexmedetomidine hydrochloride (Precedex, Hospira Inc., Lake Forest, IL), was approved by the U.S. Food and Drug Administration in 1999 initially for the sedation of intubated and mechanically ventilated adults up
to 24 hours.1 Since then, it has also been investigated for the short-term sedation of intubated and mechanically ventilated infants and children, prevention of emergence delirium after general anesthesia, sedation during noninvasive radiologic procedures, management of withdrawal after prolonged use of opioids and benzodiazepines, during extubation and postextubation, and for procedural sedation.2–4 It appears to be effective and well tolerated in preterm and full-term neonates.5 It can be used for nonintubated patients prior to and/or during surgical and other procedures.4 Dexmedetomidine hydrochloride has sedative, analgesic, and anesthetic qualities. It is a selective alpha 2 adrenergic receptor agonist of the imidazole subclass, similar in structure to clonidine.1 Activation of these receptors in the locus coeruleus results in sedation and anxiolysis.1 Because of its short half-life of 2–3 hours,1–2 dexmedetomidine is given parenterally by continuous slow infusion not to exceed 24 hours.4 The half-life is 6 minutes.2 Metabolism is by direct glucuronidation in the liver via the cytochrome P450 2A6 pathway. There is minimal excretion of unchanged drug in the urine. Neonatal profiles appear to be different as compared with older children and adults. Neonates exhibit a longer half-life and a larger area under the concentration curve, indicating that lower doses may be required to achieve the same level of sedation and to avoid adverse effects.5 Preterm neonates have decreased plasma clearance and a longer elimination half-life than term neonates.5 Preterm and term neonates have a larger volume of distribution and increased free unbound medication as compared with adults. Lam and colleagues’ study of neonates and infants with heart disease reported that administration did not result in hemodynamic instability, and a concomitant Neonatal Abstinence Syndrome (from News of the Academy – July/August 2014 Issue)
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reduction in the dosing of opioid and benzodiazepine agents was possible.1 Precedex is supplied as a clear, colorless, isotonic solution with a pH of 4.5 to 7.0. Each mL contains 118 mcg of dexmedetomidine hydrochloride equivalent to 100 mcg (0.1mg) of dexmedetomidine and 9 mg of sodium chloride in water. The solution is preservative free and contains no additives or chemical stabilizers. It is freely soluble in water. Dosing should be individualized and titrated to the desired clinical response.4 This medication should be administered using a controlled infusion device. Loading doses reported in the literature vary from 0.5–1 mg/kg over 10 minutes, followed by an infusion of 0.1–1.5 mcg/kg/hour.1–4 Precedex should not be coadministered through the same IV catheter as blood or plasma, as compatibility has not been established. 4 Precedex is incompatible with amphotericin B and diazepam.4 Precedex is compatible with 0.9% sodium chloride in water, 5% dextrose in water, 20% mannitol, lactated Ringer’s solution, 100 mg/mL magnesium sulfate solution, and 0.3% potassium chloride solution.4 Hemodynamic effects are not significantly different from baseline in most studies reviewed.1,3,4 Lam and colleagues’ study of critically ill children with congenital heart disease reported all the patients remained hemodynamically stable during the infusion.1 There were no substantial differences in major hemodynamic variables (NIRS, MAP, respiratory rate, heart rate, CVP, inotropic score) between neonates and infants undergoing surgery, heart transplantation, or other surgical procedures. Hemodynamic stability was defined as no need to escalate inotropic support, give IV fluid boluses, or hold or decrease the dexmedetomidine dose during the infusion. In addition, there were no differences in oxygen saturation, blood pH, PaO2, PaCo2, or serum bicarbonate values before or after the infusion. There were no rhythm abnormalities, no significant abdominal signs or symptoms (vomiting or abdominal distention), no withdrawal symptoms associated with termination, and no neurologic abnormalities during the infusion or after it
was terminated. Dexmedetomidine administration significantly reduced the daily dosing of opioids and benzodiazepines in the study population. Of interest, in the study by Lam and colleagues, 74 percent of participants received clonidine after the infusion was discontinued. The need for clondine was attributed to a possible withdrawal phenomenon, as this is an increasing concern in the literature. Some authors report symptoms such as increased agitation, hypertension, tachycardia, emesis, dilated pupils, diarrhea, increased muscle tone, sneezing, and seizures with abrupt discontinuation of prolonged infusions (those lasting .96 hours).2,6–8 O’Mara and colleagues report prolonged use (19 days) in a 24-week gestational age infant experiencing severe agitation refractory to high-dose IV narcotics and benzodiazepines.4 There were no significant adverse effects directly attributed to the dexmedetomidine use. The infusion allowed weaning of mechanical ventilation with eventual extubation, as well as rapid tapering of the sedatives. These researchers recommended further study of dexmedetomidine as a first-line or adjunct therapy with narcotics for sedation of ventilated infants. Adverse effects have been reported to be predictable and dose dependent.5 Symptoms reported in adults include hypotension, bradycardia, sinus arrest, transient hypertension, dry mouth, nausea, and atrial fibrillation.4 The transient hypertension was seen primarily during the loading dose administration. There is much to learn. More studies are needed to determine if dexmedetomidine is safe and efficacious for neonates. Initial studies appear promising. 1. Lam F, Bhutto AT, Tobias JD, Gossett JM, Morales L, Gupta P. Hemodynamic effects of dexmedetomidine in critically ill neonates and infants with heart disease. Pediatr Cardiol. 2012;33:1069-1077. doi 10.1007/s00246-012-0227-6 2. Hummel P. Use of dexmedetomidine hydrochloride for sedation in the NICU. NANN E-News. 3(4). http://www.nann.org/enews/July2011/feature-html. Published July, 2011. Accessed June 26, 2014. 3. Dilek O, Yasemin G, Atci M. Preliminary experience with dexmedetomidine in neonatal anesthesia. J Anaesthesiol Clin Pharmacol. 2011;27(1):17-22. 4. O’Mara K, Gal P, Ransommd J, et al. Successful use of dexmedetomidine for sedation in a 24-week gestational age neonate. Ann Pharmacother. 2009;43(10):1707-1713.
Answers to Practice Questions for Certification 1. Answer is C. In: Acute Care of at-Risk Newborns (ACoRN). Vancouver, British Columbia: ACoRN Neonatal Society; 2010:3-57. 2. Answer is C. In: Acute Care of at-Risk Newborns (ACoRN). Vancouver, British Columbia: ACoRN Neonatal Society; 2010:5-15. 3. Answer is C. In: Polin RA, & Yoder MC. Workbook in Practical Neonatology. Philadelphia, PA: Saunders Elsevier; 2007:134.
5. Pullen LC. Dexmedetomidine-effective sedative for neonates. www. medscape.com/viewarticle/818075. Published December 19, 2013. Accessed July 28, 2014. 6. Darnell C, Steiner J, Szmuk P, Sheeran P. Withdrawal from multiple sedative agent therapy in an infant: is dexmedetomidine the cause or the cure? Pediatr Crit Care Med. 2010;11(1):e1-e3. 7. Tobias JD. Dexmedetomidine: are there going to be issues with prolonged administration? J Pediatr Pharmacol Ther. 2010;15:4-9. 8. Weber MD, Thammasitboon S, Rosen DA. Acute discontinuation syndrome from dexmedetomidine after protracted use in a pediatric patient. Paediatr Anaesth. 2008;18:87-88.
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