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The Very Low Birth Weight Infant

The Very Low Birth Weight Infant. Dana Rivera, M.D. Delivery. A 800 gram female infant at 26 weeks Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption. Resuscitation. Baby pale, no respiratory effort, HR 60

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The Very Low Birth Weight Infant

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  1. The Very Low Birth Weight Infant Dana Rivera, M.D.

  2. Delivery • A 800 gram female infant at 26 weeks • Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption

  3. Resuscitation • Baby pale, no respiratory effort, HR 60 • Requires intubation with PPV with gradual increase in HR • Transferred to NICU • Perfusion remains poor with pallor

  4. ETT size selection • < 1kg: 2.5 • 1-2 kg: 3.0 • 2-3 kg: 3.5 • > 3 kg: 4 • Position? • between clavicles and carina

  5. Umbilical lines? • UVC • Intrathoracic IVC • Just above diaphragm • UAC • High: • T6-9, T7-10 • Low: • below L3

  6. Initial Hours

  7. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  8. Surfactant Deficiency SyndromeSigns and Symptoms • Respiratory distress • tachypnea • grunting • retractions • flaring • coarse breath sounds • mixed acidosis • hypoxia • CxR: ground glass underinflation air bronchograms

  9. Surfactant Deficiency SyndromePhysiology • Made by? • Type II pneumocytes • Detected by? • ~23 weeks, inadequate until ~32 weeks • Made of? • 70-80% phospholipids • Works by? • Prevents high surfacetension

  10. Laplace’s Law • Pressure = 2x tension/ radius • If surface tension equal smaller alveolus empties into larger alveolus • Surface tension of different sized alveoli not constant- smaller alveoli have lower surface tension

  11. Surfactant Deficiency SyndromeManagement • Prevention • Respiratory support • Surfactant replacement • Side effects • Antibiotics • Maintain Hct

  12. Day # 2 • NPO, placed on IVF or TPN?? • Total fluid goal greater or less than term infant?? Why? • Determining ongoing fluid needs??

  13. Day #4 • Increased ventilator support overnight • ABG: 7.22/50/50/16/-7 • Murmur

  14. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  15. Patent Ductus ArteriosusSigns and Symptoms • Murmur • Widened pulse pressure • Hyperactive precordium • Bounding pulses • Metabolic acidosis

  16. PDA- Pathophysiology • LR shunt • Pulmonary congestion • L-sided overload • CHF • Diagnosis • ECHO

  17. PDA- Management • Medical • Fluid restriction • Diuretics • Indomethacin • Contraindications • Surgical • Medical failure • Critical status • Contraindication to indomethacin

  18. Day #6 • S/P indomethacin without complications; f/u ECHO reveals closed ductus • Weaned to low ventilator support (IMV15, 15/4, 30%) • Nurses report episodes of bradycardia (60s) which respond to bagging • What are you thinking?

  19. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  20. Apnea of Prematurity • Cessation of breathing > 15 sec duration with desaturation/ bradycardia • Central, obstructive, mixed • Methylxanthine tx • Caffeine

  21. Stimulates medullary respiratory center Increased sensitivity to CO2 Enhanced diaphragmatic contractility Diuretic Enhanced catecholamine response Increased cardiac output/ HR Increased glucose (glycogenolysis) GER Caffeine

  22. Day #7 • What is the one test you should order today??

  23. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  24. Intraventricular HemorrhageSigns and Symptoms • Catastrophic • bulging fontanelle • posturing • seizures • apnea • hypotension • metabolic acidosis • drop in Hct • death • Saltatory • Cycle of deterioration and recovery • Silent: 50%

  25. Germinal matrix Developmental area of brain Periventricular b/w caudate nucleus and thalamus Provides neurons/ glial cells Richly vascularized/ loose supportive stroma Dissipates by term Poor control of cerebral blood flow Intraventricular hemorrhage (IVH)Pathophysiology

  26. Grade I Germinal matrix only (subependymal) Grade II Intraventricular/ normal ventricles Grade III IVH + dilated ventricles Grade IV IVH + parenchymal bleed Screening head u/s < ~34 weeks Management Supportive, ventricular taps, reservoirs, VP shunts Prognosis IVH

  27. Day #14 • 2 spits yesterday of small amount of formula • 10cc bilious residual this am on premature formula (16cc q3hr)

  28. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  29. Abdominal distension, tenderness, discoloration, mass Feeding intolerance Vomiting (bilious), gastric residuals, heme (+)/ bloody stools Systemic Lethargy, apnea, poor perfusion, temp instability Labs reflect sepsis leukocytosis/ leukopenia, L shift thrombocytopenia acidosis hypo/hyperglycemia hypoxia/hypercapnea NEC- Signs and Symptoms

  30. NEC- radiograph • Pneumatosis intestinalis • thickened bowel wall • sentinel loop • “soap bubble” appearance (RLQ)

  31. NEC • Pneumoperitoneum • Portal venous air

  32. NEC- Pathophysiology • Onset? • 3-10 days (24hr-3mo) • Where? • Jejunum, ileum, colon • What? • Bowel necrosis, edema, hemorrhage, perforation • Etiology? • Multifactorial • GI dysmotility/ stasis • Partially digested formula substrate for bacterial proliferation • Mucosal injury/ bacterial invasion • Mesenteric ischemia • Inflammatory mediators

  33. Medical Bowel rest Decompression Broad spectrum Abx Serial radiographs Fluid/ nutritional support Blood product support BP support Respiratory/metabolic support Surgical Pneumoperitoneum, fixed abdominal mass, persistently dilated loop, abdominal discoloration, persistent clinical deterioration Resection of necrotic bowel with ostomy Peritoneal drain NEC- Management

  34. Day # 38 • S/P NEC, no perforation, feedings resumed after 10 days bowel rest with elemental formula, reached full feeds 4 days ago • Now extubated, remains oxygen dependent

  35. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  36. Chronic lung disease (CLD or BPD) • Treatmentwith oxygen >21% for at least 28 days plus— • Mild BPD:Breathing room air at 36 weeks postmenstrual age (PMA) or discharge • ModerateBPD: Need for <30% oxygen at 36 weeks PMA or discharge • SevereBPD: Need for 30% oxygen and/or positive pressure (ventilationor continuous positive airway pressure) at 36 weeks PMA

  37. BPD- Pathophysiology

  38. Day #38 • What should have been ordered by now??

  39. Diagnosis • BPD • IVH • PDA • ROP • ROS • SDS • AOP • NEC

  40. Retinopathy of prematurity (ROP) • Risk factors? • Prematurity, oxygen exposure • Vasoconstriction vaso-obliteration neovascularization • Classification • Stages 1-5 • Zones I-III

  41. ROP- Stages & Zones • 1: Demarcation line • 2: Ridge formation • 3: Neovasculariztion/ proliferation • 4: Partial retinal detachment • 5: Complete retinal detachment • Plus disease • Tortuous arterioles, dilated venules Higher stage, lower zone- worse disease state

  42. < 1500gm or 32 weeks Selected infants >1500gm, > 32 weeks AAP policy statement Pediatrics 117(2), 2/06 ROP screening

  43. Who is the most famous person affected by ROP?

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