The Very Low Birth Weight Infant
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Transcript of 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 Requires intubation with PPV with gradual
increase in HR Transferred to NICU Perfusion remains poor with pallor
ETT size selection– < 1kg: 2.5– 1-2 kg: 3.0– 2-3 kg: 3.5– > 3 kg: 4
Position?– between clavicles
and carina
Umbilical lines?
UVC– Intrathoracic IVC
– Just above diaphragm UAC
– High: T6-9, T7-10
– Low: below L3
Initial Hours
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
Surfactant Deficiency SyndromeSigns and Symptoms
Respiratory distress– tachypnea– grunting – retractions – flaring– coarse breath sounds– mixed acidosis– hypoxia
CxR:
ground glass
underinflation
air bronchograms
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 surface tension
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
Surfactant Deficiency SyndromeManagement
Prevention Respiratory support Surfactant replacement
– Side effects
Antibiotics Maintain Hct
Day # 2
NPO, placed on IVF or TPN??
Total fluid goal greater or less than term infant?? Why?
Determining ongoing fluid needs??
Day #4
Increased ventilator support overnight
ABG: 7.22/50/50/16/-7
Murmur
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
Patent Ductus ArteriosusSigns and Symptoms
Murmur Widened pulse pressure Hyperactive precordium Bounding pulses Metabolic acidosis
PDA- Pathophysiology
LR shunt– Pulmonary congestion– L-sided overload– CHF
Diagnosis– ECHO
PDA- Management
– MedicalFluid restrictionDiureticsIndomethacin
– Contraindications
– SurgicalMedical failureCritical statusContraindication to indomethacin
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?
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
Apnea of Prematurity
Cessation of breathing > 15 sec duration with desaturation/ bradycardia
Central, obstructive, mixed
Methylxanthine tx– Caffeine
Caffeine
Stimulates medullary respiratory center
Increased sensitivity to CO2
Enhanced diaphragmatic contractility
Diuretic
Enhanced catecholamine response
– Increased cardiac output/ HR
Increased glucose (glycogenolysis)
GER
Day #7
What is the one test you should order today??
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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%
Intraventricular hemorrhage (IVH)Pathophysiology
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
IVH
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
Day #14
2 spits yesterday of small amount of formula
10cc bilious residual this am on premature formula (16cc q3hr)
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
NEC- Signs and Symptoms
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- radiograph
Pneumatosis intestinalis
thickened bowel wall
sentinel loop
“soap bubble” appearance (RLQ)
NEC
Pneumoperitoneum
Portal venous air
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
NEC- Management
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
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
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
Chronic lung disease (CLD or BPD)
Treatment with oxygen >21% for at least 28 days plus—
Mild BPD: Breathing room air at 36 weeks postmenstrual age (PMA) or discharge
Moderate BPD: Need for <30% oxygen at 36 weeks PMA or discharge
Severe BPD: Need for 30% oxygen and/or positive pressure (ventilation or continuous positive airway pressure) at 36 weeks PMA
BPD- Pathophysiology
Day #38
What should have been ordered by now??
Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
Retinopathy of prematurity (ROP)
Risk factors?– Prematurity, oxygen exposure
Vasoconstriction vaso-obliteration neovascularization
Classification– Stages 1-5– Zones I-III
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 venulesHigher stage, lower zone-
worse disease state
ROP screening
< 1500gm or 32 weeks
Selected infants >1500gm, > 32 weeks
AAP policy statement– Pediatrics 117(2), 2/06
Gestational age Postmenstrual Chronologic
22 31 9
23 31 8
24 31 7
25 31 6
26 31 5
27 31 4
28 32 4
29 33 4
30 34 4
31 35 4
32 36 4
Who is the most famous person affected by ROP?