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Julie Donnelly

on 12 September 2012

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nicu THERMOREGULATION protocol Warm babies are happy babies! Body temperature is one of the primary VITAL SIGNS. Why worry about thermoregulation? A = Airway
B = Breathing
C = Circulation
D = Degrees In terms of ABC's, think: Shivering, which is the main way older children and adults generate heat, is impossible or not effective in infants. GOT HEAT? Neonates and young infants generate heat by burning brown fat. Brown fat is an energy source for infants.
It can be found near kidneys and adrenals, neck, mediastinal, scapular and axillary regions. What's that? Brown fat is typically not produced until 26 to 30 weeks gestation.
Conversion of brown fat to heat uses oxygen and glucose, thereby causing hypoxia and hypoglycemia.
Growth is affected, as calories are used to stay warm rather than to promote weight gain. Once it's gone, it's GONE. HYPOTHERMIA Body cool to touch
Mottling or pallor
Extended capillary refill
Poor feeding
Increased gastric residuals
Hypotonia progressing to lethargy
Periodic breathing progressing to apnea
Bradycardia Preterms especially at risk Thin skin and blood vessels close to surface
Little subcutaneous fat
Unable to maintain flexion
Four times greater surface area to body mass than adults
Up to ten times insensible water loss compared to adults
Low stores or absence of brown fat Maintaining body temp is a lot of work! How can we help? Avoiding hypothermia is a three-part process: 1. Minimize Heat Loss Consider the four methods of heat loss and intervene appropriately. 1. Convection: Occurs when airflow carries heat to or away from the body. Warm babies:
Consume less calories
Consume less oxygen
Perfuse more efficiently
Gain more weight! 2. Radiation: Occurs between two objects that are not in direct contact 3. Conduction: Occurs between objects that are in direct contact 4. Evaporation: Occurs when liquid is turned to vapor 2. Provide Most Efficient Heated Environment Who goes where? ISOLETTES RADIANT WARMERS OPEN CRIBS HUMIDIFIED ENVIRONMENTS All neonates weighing 2500 grams or less and/or less than 35 weeks gestation should be admitted into Giraffe Convertible Omnibed
Closed isolette mode always preferred for neonates not requiring frequent interventions or surgical procedures
Neonates weighing less than 1000 grams should be placed on skin mode with set point 36.3 to 37.0 C
Neonates weighing more than 1000 grams should be placed on air mode, utilizing Comfort Zone in Omnibed to establish air temperature range Infants weighing more than 2500 grams and/or greater than 35 weeks gestation should be admitted into a Giraffe Warmer Bed
All infants in radiant warmers should be placed on skin mode with suggested set point starting at 36.5 C, with acceptable range for set point
36.0 to 37.0 C
Manual mode should only be used to heat bed's surface before receiving infant. Do not use manual mode to warm a cold infant (axillary temp less than 35.5 C)
A cold infant will be more safely warmed by gradually increasing temp probe set point in skin mode. Start with set point .5 degree C above current axillary temp. Check axillary temp every 30 minutes and increase set point by .5 degree C until desired temp has been reached
For infants weighing greater than 2500gm radiant warmer may be turned off and infant bundled when medically stable. Apply hat, tee shirt and no more than two receiving blankets. Check temp at start of “open crib trial,” at one hour, and then every 3-4 hours for first 24 hours. If axillary temp falls below 36.4 C, resume radiant heat.
If infant fails wean to open crib, wait minimum 24 hours before attempting another open crib trial. Corrected gestational age 34 weeks or greater
Current weight 1800 grams (1500 grams for SGA)
Weight gain for at least three consecutive days
Comfort Zone-determined air temp 29.5 degrees C or lower
Axillary temps consistently greater than 36.5 degrees C Corrected gestational age less than 30 weeks
Current weight less than 1000 grams
Current age less than 14 days Do not raise bed canopy unless absolutely necessary
Do not place bed near air vent whenever possible
Cluster care to minimize opening of portholes
Utilize air boost curtain whenever entering isolette Keep isolette walls warm by covering with quilts Avoid placing infant directly on cold surfaces (scales, X-ray plates)
Always pre-warm admission beds
When removing infant from isolette for family to hold, wrap in linen that is already on bed
Never place "cold" hat or linen on an already cold baby
Encourage kangaroo care
Pre-warm nesting devices in blanket warmer Provide heat source during bath whenever possible
Dry infant thoroughly and immediately after bathing
Promptly change soiled diapers, surgical dressings and linens
Utilize humidification if appropriate Isolettes Radiant Warmers Open Cribs Humidified
Environments SO THEN WHAT ? Because, premies are porous! Why Humidify? 3. MONITOR AND MAKE ADJUSTMENTS TEMP TAKING METHODS: Axillary temp is the preferred method on all neonates

Ideal axillary temp range is 36.5 to 37.3 C

Rectal temps should not be taken on any neonate less than 2000 gm without physician consent; probe should not be inserted beyond 1cm

Rectal temps are typically as much as 1.0 C higher than skin temps as they are more indicative of core body temp

Premature infants will likely have skin temps closer to core body temps than term infants due to lack of subcutaneous fat

Very edematous or LGA infants will likely have a larger discrepancy between skin and core body temp PROBE PLACEMENT TIPS: Be certain that temp probe is flat (not perpendicular) to skin surface

Probes should always be covered with a foil heat reflector; this assures the probe is reading the neonate’s skin temp and not the ambient air temp

Please use only hydrocolloid probe covers

It is acceptable to place tegaderm over foil cover to assure edges are sealed to skin

Ideal probe placement is below the rib cage, on the outer aspects of the abdomen (when infant supine) or upper flank (when infant prone). This will help avoid areas where there is brown fat.

If surgical dressings or anomalies prevent ideal probe placement, axillary placement is acceptable. Please note the arm must be down and skin temperature set point should be increased by 0.5 C

In cases of severe edema, axillary probe placement may also need to be considered as skin temp will be a less accurate reflection of core body temperature. As brown fat stores are depleted anaerobic metabolism is used to increase heat production in a process called non- shivering, or chemical, thermogenesis.
This produces lactic acid which causes subsequent metabolic acidosis.
Norepinephrine is released at the site of brown fat metabolism which causes peripheral and pulmonary vasoconstriction.
This can lead to shock, increased risk for PDA, NEC, and PPHN …..

PS: We should never ask “Can I cold stress this baby?” THE COMFORT ZONE What is it? When to use it? •Neonates in closed Omnibed isolettes weighing less than 1000 gm should be kept on skin mode with set temp 36.5 to 37.2 C
•Neonates more than 1000 gm should be converted to air mode utilizing Comfort Zone range provided in Omnibed data source How does it work? • The goal will be a gradual weaning process from the isolette to an open crib
• As the infant gains weight the air temp range will decrease
• The Comfort Zone range should be evaluated and adjusted as needed every 24 hours when the infant is weighed
• Skin temp probe is no longer needed and skin temperature no longer needs to be documented
• The bed only provides the care giver with suggested air temp range. The caregiver must initially set and adjust the air temperature as needed. When transitioning to air mode start with air temp in mid range. Consider infant’s temperature trend over previous twenty four hours
• Dry weight (dose weight) should be used in infants too medically unstable to weigh or those with significant edema
• When nesting devices are used recommended air temp ranges may need to be reduced by .5 to 1 degree C
• Remember to utilize air boost curtain when port holes are opened and especially when doors are opened for procedures to minimize convective heat loss 1. Minimize Heat Loss
2. Provide Most Efficient Heated Environment
3. Monitor and Make Adjustments standard feature of Giraffe products
will replace use of traditional NTE charts (outdated data)
Comfort Zone is a recommended reference range for air temperature based on current body weight, gestational age at birth, and postnatal age DID WE TRY TOO HARD? Overly aggressive interventions to replace heat loss and/or inappropriate use of equipment can lead to… HYPERTHERMIA Signs/symptoms:

Tachycardia Flushing
Hypotension Skin Temp > Core Temp
Tachypnea Irritability
Poor feeding Classified as axillary temp > 37.5 C SOME COMMON MISTAKES Radiant warmer left in manual mode too long
Temp probe in wrong place (on extremity or rib cage)
Temp probe loose (bed will compensate and overheat)
Comfort Zone not appropriately set
Nesting devices (may need to decrease Comfort Zone .5 to 1 C)
Humidity not being weaned as recommended
Hats and socks not always needed in isolette
Overbundling/overdressing infants in open cribs FEVER vs. IATROGENIC HYPERTHERMIA? recent CBC recent immunizations
hydration status change in respiratory status
central line nasal secretions
viral exposure medications (PGE, lasix)
dextrostick instability hypotension
NAS history wound/incision changes
recent surgery active phototherapy REMEMBER: simply turning down the bed can mask a real fever so consider the whole picture first! SO THEN WHAT ? As brown fat stores are depleted, anaerobic metabolism is used to increase heat production in a process called non- shivering, or chemical, thermogenesis.
This produces lactic acid which causes subsequent metabolic acidosis.
Norepinephrine is released at the site of brown fat metabolism which causes peripheral and pulmonary vasoconstriction.
This can lead to shock, increased risk for PDA, NEC, and PPHN... COLD STRESS PS: We should never ask, “Can I cold stress this baby?” POORLY PLACED OR LOOSE PROBES CAN CAUSE FALSE TEMPERATURE READINGS AND THEREFORE OVER/UNDER HEATING OF THE NEONATE A FEW FINAL REMINDERS Be sure to chart changes in CERNER regarding temperature mode choices, set point adjustments and open bed trial start date. Thermoregulation decisions are nursing judgments based on protocol guidelines. No physician order is required to wean an infant to open crib. However, please alert neonatal team when infant is no longer in heated environment. Close Omnibed canopy whenever possible. Utilize air boost curtain when opening portholes or dropping door. Always warm bed in manual mode for new admissions. Infants in isolettes should not be clothed or swaddled, though hats and/or socks are acceptable. Assure phototherapy units are angled and not blocking radiant heat from reaching infant. Ideally, isolettes should be changed every week based on patient acuity and bed availability. Infants less than 1500 gms may be removed from isolette and held for 30 to 60 minutes every 24 hours by primary caregivers only. Encourage Kangaroo Care per policy. And remember... A FEW FINAL REMINDERS
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