SCN & NICU STARTER PACK (TAGGING)

SCN

+ SCN usually only have AM ROUND and PM ROUNDS usually the SP and MO looks at new
cases, ONCALL ROUND mo will review all cases but usually quick round
+AM REVIEW is a MUST, update all previous day findings, management and if there is a new
impression or resolved issue. Also calculate IO (intake output),U/O (urine output) and BO
(Bowel Output)
+ When putting notes for maternal hx, please put also mother fbc including tw, hct, hb and plt
+ Also please put the investigation's result properly in the notes and not just , result noted. This
is to make it easier for the next HO to update the notes.

+SCN ADMISSION CLERKING​; what to do when a case come in

- Clerk case obviously, maternal hx ( if outborn patient - take some time to see if there is
any maternal risk factor, antenatally mother ada apa)
- Calculate how much feeding to give (feeding in SCN can give in 5cc increment, 25, 30,
40 etc)
- Inform MO - important as Mo will be in NICU so don’t wait until you have 10+ new cases
before informing.
- Some case might need to take bloods, blood culture, put branula

+ Calculate Hour OF LIFE (HOL). If more than 72 Hours you can start putting Days Of Life but
also put HOL (important to calculate Photo Level in jaundice later)
+ put the current weight of the baby - important if need to check any weight loss - but always
use highest weight for feeding or calculating antibiotic
+ KNOW how to calculate Preterm and Term baby’s fluid requirement/feeding (cc/kg/day)
+ Common case, NNJ above photo level, risk of sepsis completing 48H temp monitoring,
presumed sepsis to start abx, weight loss above 7%
+ There will be a lot of discharges after AM Round and after there will be lots of admission either
from PostNatal Ward, NICU transfer or ED.

FEEDING
+ 1ST 24 HOL - 60CC/KG/Day
+ 48 HOL - 90CC/KG/Day
+ 72 HOL - 120CC/KG/Day
+ 96 HOL - 150CC/KG/Day
+ More than that can go up to 180CC/KG/Day
+ Above is the Total Fluid requirement per day meaning how much we can give the baby
per day but to note for term baby the feeding is every 3 hourly (8x/day) and for
premature baby is 2 hourly (12x/day)
How much to give per hour

Term baby = ​total fluid (TF) x hwt (always use highest weight)
8

Prem baby divide by 12

Calculating how much you give TF according to 3hourly feeding

TF = ​feeding 3 hourly x 8
Wt

Eg: Term baby 3kg at 15HOL

FEEDING = ​60cc x 3 ​ = 22.5cc so you can round up 25cc/3 hourly

8

TF = ​25 X 8​ = 67cc/kg/d
3

So then you can put in notes: start feeding 25cc/3hourly (TF 67cc/kg/d)

Techniques to master
- Taking bloods - Always compress longer time for blood taking, so it won't get bruises so
bad ,easier for next blood taking
- Putting in brannula
- Blood c+s
- Calculating photo level using Jaundice graph
- Calculating antibiotic dose
-
COMMON CASES AND PLANS

1/ NEONATAL JAUNDICE - the single most important thing to master for SCN

+ Baby usually will be admitted to SCN from PNW or KK referral for tsb above PL (photo level)
or IPL (intensive photo level) , if above IPL inform MO STAT!
+ common clerking questions:
- how’s the baby feeding at home
- how often (every 1 hour ke, 2 hour ke) and how long during each feed (10 min ke, 20
min ke),
- Exclusively BF or Mixed feeding
- How many time PU and BO per day, what colour is PU and BO, is the diaper full when
PU,
 - mother taking any traditional meds,
- any siblings hx of NNJ
+ Know how to stratify the risk of the baby, its either

RISK: ​HIGH RISK​ (HR), ​MODERATE RISK​ (MR), ​LOW RISK​ (LR)
LR: totally no risk
MR: 1 risk
HR: > 1 risk

Know the differences between 'TCB' and 'TSB', Learn How to Read the Chart

Risk Factors:
1/<38 completed week
2/ G6PD, RH -ve mother
3/ Maternal Blood Group (MBG) O+ve with Retics >5.0 (if retics is <5.0 can downgrade the O+
risk to one risk below)

Example how to write traced IX

TSB @ 25 HOL TB 110 DB 10.0 IB 100.0 (PL 121 IPL 171)---MR

Always write ET Level if TSB above IPL level

TSB @ 25 HOL TB 190 DB 10.0 IB 180.0 (PL 121 IPL 171 ET_____)---MR

Plan:
+ Upon admission always ask blood taken at what time and stratify the baby again (most of the
time the tsb taken at KK is capillary TSB and might be less accurate than venous TSB that we
take so usually we will repeat TSB on admission, however you can consult mo also if they want
to repeat TSB on admission or cm)
+ If baby is above IPL, inform MO, and 4HOURLY blood taking
+ Assumed MBG O+ve as one risk even no Retics taken prior to this, take TSB and Reticulocyte
count on admission and re-stratify the baby after result out
+ Always calculate weight loss prior to blood taking, any weight loss >7%,to take RP

2/ WEIGHT LOSS
Birth weight - current weight / birth weight x100%: any loss>7% is significant
+ Always use the weight from our penimbang in admission instead of from KK referral letter
+ Feeding history from mother is important

plan:
- remember to take RP
- can give feeding more than usual
- eg day 5 baby instead of giving ngam ngam TF 150cc/kg/day, can give TF 165, 167, 170 suka
hati lah
3/ PRESUMED SEPSIS
+ common case in newborn admitted to SCN
+ know diff of Risk Of Sepsis and Presumed Sepsis and sepsis, read up**
+ Roughly for your understanding: presumed sepsis we cover with antibiotic ,Risk of sepsis just
temperature monitoring for 48H

plan: (baby BWT:2.68kg,term 37 week)

+ upon admission, Set line with ​Blood C+S, FBC, CRP​ prior to IV abx
+ Check the NICU ABX guidelines always for antibiotic dose but generally
+ Start IV C -Penicillin 100,000U/KG 12 HOURLY (*note that its 24hourly not BD)
+ Start IV Gentamicin 4mg/KG 11mg 24 HOURLY (*not OD), gentamicin is ototoxicity and
nephrotoxicity,
+ if u get value of 11.1-11.5, round off to 11mg**, if 11.8, 11.9 then yes, make it
12mg.anyways,it depends on MO also.
+ Last but not least, get MO’s sign for medication chart

4/ RISK OF SEPSIS
+ common risk: mother PROM>18 HOURLY,or GBS +ve adequately covered with iv abx
+ temperature monitoring for 48HR,can be done in postnatal ward, baby admit SCN for
monitoring if mother discharge.
+ no abx

5/ G6PD DEFICIENCY/ INTERMEDIATE

Deficient –no need for assay
Intermediate- need to call WCH HKL LAB for G6PD assay appointment date 6/12

plan:
for monitoring of Jaundice for 5 days
ideally daily TSB, but depends on MOs
G6PD counseling to parent (got pamphlet)
Intermediate- G6PD assay appointment date 6/12,blood taking on the same day or one day
earlier in SOC paeds by 8am, blood will be dispatched out to HKL, TCA 3/12 at soc paeds to
review result

6/ RH –ve mother

plan:
Send FBC, RETICs, Coombs, Baby blood group & Rh-typing, TSB
watchout for jaundice

NICU
+ A bit different from SCN, NICU has AM ROUND, PM ROUND and Oncall round.
+ In each round mo will expect you to calculate the I/O, BO and U/O
+ AM REVIEW is the utmost important in NICU as it summarizes everything that has happened
the day prior to the baby. Aside from the common things we update during AM Review, always
remember to update:
- For prem baby - update the Corrected Age for the baby.
- Current weight and highest weight of the baby. Baby in incubator will be weight during
the night prior and in cot baby will be weight during the bath time in the morning
- Always update the TF according to latest highest weight of the baby
- Ventilation history, when the baby intubated, what settings, when extubated, since when
in room air, how long baby in Nasal prongs
- Antibiotic - if already off, when was offed, how long was given
- Cranium USS - when was the last cranium uss and what was the findings
- Any current issue and resolved issue to be updated each AM REVIEW

Feeding
+ Same with in SCN however NICU is a bit restricted in increasing the feeding, instead of
using increment of 5cc, sometimes they only increase 2, or 3 cc each time so always
consult MO - and don’t forget to write in the patient’s file the date and time to increase
the feeding and by how much.
+ There’s also Safe Increment which is how much you can increase feeding for the baby
each feeding but a bit confusing to better ask MO.
+ Some babies will be kept NBM on admission. Fluid requirement is the same according to
day of life. However, you need to calculate Total IVD rate per hour to give to the baby

IVD TR = ​TF x HWT

24

If the baby already started feeding with IVD you need to subtract the feeding given from the total
fluid before calculating the IVD TR

IVD TR with feeding =

((TF x HWT) - (Feeding 3 hourly x 8))

24

For example: Term baby D2 Of Life, HWT 2.7kg,

IVD TR = ​90 X 2.7​ = 10.1cc/kg/hr

24
Child is then started on feeding 5cc/3hourly

IVD TR with feeding = ​((90 x 2.7) - (5 x 8))​ =

24

243 - 40​ = 8.46cc/kg/hr

24

Techniques to master
+ Preparing stuff for Blood c&s and doing Blood C&S (see below)
+ Preparing stuff for UVC/UVA (see below)
+ Doing ECG on babies
+ How to take and use blood gas machine
+ STANDBY for RESUS - follow your senior, read up on NRP (the best is to be able to go
for Standy by yourself on your third day of tagging)
- There is no specific person for standy, depending on who is available at that time
when you hear there is a standby, JUST GO even if you have rounds. MO will
understand. If you have things to do urgently, make sure you pass over to
someone that can go.

Common Blood ix to know:

+ Early NNJ: FBC, RETICS, TSB
+ Prolonged Jaundice (D14 term, D21 Prem): LFT, TFT, FBC, UFEME
+ PREM Ix: FBC, RP, LFT, RETICS, CA, PO4

IX Cutoff point
+ Twc > 25
+ Crp > 5
+ HCT > 65
+ Creatinine > 70

Supplements:
+ Started for premature babies at D14 of life and includes
- SYRUP FOLIC ACID 0.5ML OD
- SYRUP APPETON 1ML OD
- FAC (Ferrite Ammonium Citrate)

FAC dose
+ D14 - D20 - 2mg/kg/dose
+ D21 - D27 - 3mg/kg/dose
+ D28 and beyond - 4mg/kg/dose
Calculating FAC dose: ​HWT x dose x 5
84

Eg: prem baby day 15 of life 2.1kg

FAC = ​2.1 x 2 x 5​ = 0.25 (round off) = 0.3ml OD

84

STUFF TO PREPARE

1/ Blood gas
+ Dressing towel
+ CC towel
+ Gown
+ Blood C+S set/ medium dressing set
+ Glove according to hand size
+ 3cc syringe
+ 3 blue needle
+ Cotton
+ Gauze
+ Chlorhexidine according to protocol
+ 70% alcohol to wash trolley
+ Blood c+s bottle
+ Brannula if setting a line
+ Fbc + crp bottle if taking blood also

2/ UAC/UVC
+ UVC set
+ Dressing Towel
+ CC towel
+ Gown
+ Glove
+ Cotton
+ Gauze
+ Hep Saline x5
+ 3 way red x 1
+ 3 way blue x 1
+ Blade
+ suture
+ 10cc syringe x2
+ UAC - size (4 or 5) ask MO