Neeraj Gupta Neonatal sepsis & resuscitationNeeraj Gupta Additional Professor Department of...
Transcript of Neeraj Gupta Neonatal sepsis & resuscitationNeeraj Gupta Additional Professor Department of...
Neeraj Gupta
Additional Professor
Department of Neonatology
All India Institute of Medical Sciences (AIIMS)
Jodhpur, Rajasthan, India
MD, DM (Neonatology), MAMS
Neonatal sepsis & resuscitation
Value of Neurological Examination
in NICU
Neeraj Gupta
All India Institute of Medical Sciences (AIIMS)
Jodhpur, Rajasthan, India
Neonatal Neurological Examination-
Is it really useful?
Truth!
What’s is the utility of neurological
examination in NICU?
Diagnosis
Treatment
Prognosis
What is it’s diagnostic role in NICU?...
Gestational age assessment- New Ballard Scoring
What is it’s diagnostic role in NICU?...
Part of daily assessment
Level of alertness
Posture
Response to handling
Spontaneous movements
Abnormal movements
Sepsis
Metabolic conditions (hypoglycemia, polycythemia)
Neurometabolic disorders
Picks abnormal infants warranting further
evaluation
What is it’s diagnostic role in NICU?...
27 week/800 g/SFD/M
Required PPV, APGAR 3 & 7/Surfactant & on CPAP/26
hours of life
Sudden stupor to comatose
Respiratory abnormalities (hypoventilation to apneas)
Decerebrate posturing
Picks catastrophic events
What is it’s diagnostic role in NICU?...
38 week/3000 g/AFD/M/70 hours of life/outborn
Referred due to significant jaundice with serum
bilirubin near exchange
On intensive phototherapy
After 4 hours, lethargic, not sucking on breast with
?retrocollis
Picks significant changes warranting
intervention
What is it’s diagnostic role in NICU?...
Neurological Examination- Diagnostic role
Identifies abnormality
Localize abnormality & determines severity
Help in making differential diagnosis
Diagnose a fixed deficit or syndrome
Serve as initial examination in continuing evaluation
How it helps in treatment?...
Infant ≥36 week, ≥ 1800 gm
ANDPostnatal age <6 hour
Evidence of asphyxia (Any one)1. Blood gas (pH or BD)
2. APGAR ≤5 at 10 min
3. Need of PPV at 10 min
AND
Criteria for administering Therapeutic hypothermia
1. Evaluation is primarily clinical
2. Important to select right infant at right time
3. Need of serial examination in first few hours
Evidence of moderate to severe HIE
Seizure OR Altered consciousness/tone/reflexes (Any two)
What are the various scoring systems used
for assessing HIE?
Alertness, Seizures, Tone, Reflexes
How it helps in prognosis?...
A peak score of ≥15 has PPV of 92% for abnormal outcome
How it helps in prognosis?...
Sarnat & Sarnat Staging
NICHD Network – Factors ↑ risk of death/disability at
18 months
1. Severe encephalopathy <6 hr
2. Persistence of moderate to severe encephalopathy
throughout 72 hr period of cooling
3. At discharge - hypertonia, fisted hands, abnormal
movements, need of gavage feeding
Shankaran S et al; J Pediatr 2012
What is it’s prognostic value?...
Abnormality Increased risk of CP (predominantly term infants
with asphyxia)
Tone abnormalities of limb ortrunk
12-15 times
Diminished cry > 1day 21 times
Weak or absent sucking 14 times
need for gavage or tube
feedings
16-22 times
Diminished activity >1 day 19 times
What is it’s prognostic value in preterm
infants?
Systematic review- 4 studies
High risk infants
Accuracy of predicting cerebral palsy at 2 years
88% sensitivity & 87% specificity
Bosanquet et al; Dev Med Child Neurol 2013
Does one scheme of examination suffices
all purpose across all gestations?...
Noble et al; Dev Med Child Neurol 2012
Does one scheme of examination suffices
all purpose across all gestations?
Discriminative Tool All assessment scales
Evaluative Tool
Prediction Tool
Test for Infant Motor
Performance (TIMP)
General Movements
Noble et al; Dev Med Child Neurol 2012
General Movements- What are these?...
Without being triggered, fetal & neonatal nervous system
generates variety of motor patterns involving whole body
(Prechtl 1990)
Consist of movements involving whole body in a variable sequence of arm, leg, neck, and trunk movements
Varies in intensity, force, speed, with a gradual beginning & end
Complexity makes them vulnerable to brain dysfunction,
therefore sensitive indicator of brain injury
General Movements- What are the various
types?
Normal general movements: Writhing, fidgety
Abnormal general movements: Poor repertoire, cramp synchronized
General Movements
Normal GM
1. Involving the whole body
2. Variable movement sequences
3. Wax and wane in intensity, force,
speed
4. Have gradual beginning & end
5. Superimposed rotational movements
6. Movements: fluent and elegant
General Movements
Poor repertoire
1. Look rigid
2. Lack normal smooth & fluent character
3. All limb and trunk muscles contract &
relax almost simultaneously
Cramped synchronized GMs
Fig. Pictures show synchronous lifting of the four limbs in sequence,
followed by extension and adduction
General Movements- Accuracy of
predicting cerebral palsy at 2 years
Modality No. of studies Sensitivity Specificity
Bosanquet et al; Dev Med Child Neurol 2013
What are the limitations in doing
comprehensive neurological exam in NICU?
Cardiorespiratory instability
Mechanically ventilated
Central lines
Monitoring devices
Sedation
Risk of causing IVH by undue & excessive
handling
What is feasible to assess in sick neonates
in NICU?
Level of consciousness
Seizures
Posture
Movements- General and on handling
Reflexes
Neonatal Intensive Care Unit Network Neurobehavioral
Scale (NNNS)- Research tool
How to improve yield of neurological
examination?
Perform serial examinations
Correlate with investigations - better diagnostic &
prognostic yield
Take Home Message
Neurological examination – inherent part of evaluation
Has diagnostic, therapeutic and prognostic importance
Simple assessment should be done in all neonates in
NICU
Comprehensive assessment in specific cases to fulfill
diagnostic or prognostic goal
Correlate with other diagnostic modalities
Thank you for your kind attention!