khalid altirkawi, md king saud university college of medicine department of pediatrics/division of...
TRANSCRIPT
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Khalid Altirkawi, MD
King Saud UniversityCollege of MedicineDepartment of pediatrics/Division of Neonatal Medicine
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This presentation is intended for helping medical students and the junior trainees upon their early days in the NICU. It is certainly NOT directed to the most seasoned staff.Please provide me with your feedback at: [email protected]
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Definitions
Age
GA = gestational age CGA = corrected gestational age PCA = post conceptional age PMA = post menstrual age
Chronologic age Postnatal day of life = start at 1 on birthday Postnatal age = start at 0 on birthday
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Definitions
Birthweight
LBW = low birthweight <2500 g
VLBW = very low birthweight <1500 g
ELBW = extremely low birthweight <1000 g
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Signs and Symptoms
Cyanosis. Pallor. Convulsions. Lethargy. Irritability. Hyperactivity. Poor feeding.
Fever. Apnea. Jaundice. Vomiting. Diarrea. Abdominal
distension. Pseudoparalysis.
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Cyanosis
Central cyanosis :
Respiratory insufficiency. CNS depression. Cyanotic heart disease. PPHN. Hypoglycemia Sepsis
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Peripheral Cyanosis
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Pallor
Anemia. Acute hemorrhage. Hypoxia. Hypoglycemia. Shock. Adrenal failure. Sepsis.
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Convulsions
Electrolyte abnormal-ities : Ca, Na.
Hypoglycemia. Inborn error of
metabolism Drug withdrawal Pyridoxine
deficiency
Cerebral anomalies. Cerebral Infarction. Intracranial
hemorrhage. Birth Asphyxia. Meningitis. Familial
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Convulsions
Type of convulsions Subtle, focal or generalized
Needs to be distinguished from: Jitterness Apnea
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Lethargy
Asphyxia. Hypoglycemia. Sedation. Cerebral defect. Inborn error of metabolism Sepsis
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Irritability
Intra-abdominal conditions. Meningeal irritation. Drug withdrawal. Congenital glaucoma. Sepsis
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Poor Feeding
Prematurity Sick newborn infants: Sepsis
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Thermal regulation abnormalities
Hypothermia (more common) Hyperthermia:
Environmental. Over clothing. Dehydration. Infection.
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Jaundice
First 24 hours (almost always pathologic) :
Erythroblastosis fetalis. Sepsis. CMV. Congenital rubella. Toxoplasmosis.
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Jaundice
After 24 hours :
Physiologic Hemolytic anemia IEM: e.g. Galactosemia Hepatitis Congenital infections Sepsis
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Vomiting
GI obstruction Pyloric stenosis Overfeeding Milk allergy Increased ICP Sepsis
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Abdominal Distention
GI obstruction. Abdominal mass NEC Ileus
Hypokalemia Sepsis..
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Pseudo-paralysis
Fracture Dislocation Nerve injury Osteomyelitis
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Formerly known as hyaline membrane disease (HMD)
Respiratory Distress Syndrome (RDS)
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RDS
Primary surfactant deficiency and “immaturity”
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RDS
Course: 3-4 days
Prevention: antenatal steroids, control of maternal diabetes
Diagnosis: Clinical signs: Grunting, Retractions,
Nasal flaring, Cyanosis Radiographic signs: Diffuse, Ground-
glass opacification, Air bronchograms, Low lung volumes (if not ventilated)
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RDS
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GBS pneumonia
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Transient tachypnea of the newborn (TTNB)
Fluid in the fissureFluid in the fissure
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Meconeum aspiration syndrome(MAS)
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RDS
Treatment: exogenous intratracheal surfactant
Surfactant lowers surface tension at air-fluid interface
Within minutes, improved oxygenation and increased FRC at lower airway pressures
Single treatment is enough for most newborns because type II pneumocytes recycle surfactant
Second dose may be needed in >6 hours if surfactant inhibition occurs (e.g. in MAS)
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Pneumothorax
Aymptomatic (1-2% of all newborn infants)
Spontaneous vs. secondary
Clinical manifestations
Diagnosis Management
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Diaphragmatic Hernia
Cong. Or acquired Most often left, and through the poster-
lateral segment of diaphragm. Respiratory Distress (usually severe),
cyanosis, bradycardia, scaphoid abdomen
Diagnosis Management Outcome
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Diaphragmatic hernia (L)
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Diaphragmatic hernia (R)
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Chronic lung disease(CLD)
Broncho-pulmonary dysplasia (BPD)
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CLD
Lung injury due to:
Barototrauma
Volutrauma
Oxygen toxicity
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BPD
Defined by the need for oxygen therapy or respiratory support at 36 weeks postmenstrual age (PMA)
Prophylaxis and Treatment
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Apnea of prematurity(AOP)
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AOP
Cessation of respiration for 20 seconds, or for 15 seconds associated with cyanosis, pallor or bradycardia
Respiratory drive in preterm infants is Less developed in response to hypercarbia Transiently increased then decreased by
hypoxia
Preterm infants are at 3-4 increased risk of SIDS than term infants
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AOP
More common during sleep Uncommon if birth after 34 weeks of
gestation May persist in VLBW infants until 44
weeks postmenstrual age. May recur following general anesthesia:
Preterms < 44 weeks PMA who receive GA require 24 hour monitoring
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Types of AOP
Central apnea Lack of respiratory drive and effort, Typically
brief
Obstructive apnea Presence of central drive and respiratory efforts Cessation of respiratory airflow due to airway
obstruction
Mixed apnea Central apnea in response to hypoxia of
obstructive apnea Most common, Can be quite prolonged
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Identifiable Causes of Apnea
Prematurity/immaturity Hypoglycemia Drugs Seizures CNS injury Sepsis!!!
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Treatment of severe AOP
Methylxanthine drugs (e.g. Caffeine) Central stimulation
Nasal CPAP Splints upper airway obstruction Maintains FRC stabilized oxygenation
Low flow nasal oxygen Stabilizes oxygenation
Be careful not to hyper-oxygenate!
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Periodic breathing
Recurrent sequences of pauses in respiration lasting 5 to 10 seconds followed by 10-15 seconds of rapid respiration
Evaluation and Treatment are not indicated
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Patent Ductus Arteriosus(PDA)
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PDA
Persistence of fetal ductus arteriosus Blood flow determined by relative
pressures Volume overload once pulmonary vascular
resistance decreases
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PDA
Clinical Signs:
Continuous murmur Best heard at upper left sternal border Diastolic component is difficult to hear
Decreased systemic diastolic blood pressure “bounding” pulse
Increased O2 and ventilatory requirements
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PDA
Diagnosis: Echocardiography is the gold standard
Treatment: Symptomatic
Indomethacin if < 14 (to 28) days chronologic age
Surgical ligation if 2 courses of Indomethacin were unsuccessful or contraindicated
Asymptomatic closure after 6 months
Coil embolization Video-assisted thoracoscopic surgery (VATS)
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Intraventricular hemorrhage(IVH)
Periventricular hemorrhagic infarction(PVHI)
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IVH & PVHI
Grade I (Mild): Germinal matrix bleeding
Grade II (Moderate): IVH filling 10-50% of the ventricles
Grade III (Severe): ventricles >50% filled with blood, typically distending ventricle
Grade IV: Periventricular hemorrhagic infarction
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Grade I
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Grade II
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Grade III
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Grade IV
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Necrotizing Enterocolitis(NEC)
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NEC
Acute multifactorial intestinal necrosis syndrome
Ischemia Infection and Inflammation Poor host protective responses
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Clinical Presentation
Systemic signs
Respiratory distress or apnea
Lethargy Temperature instability Irritability or poor
feeding Shock Acidosis Oliguria Bleeding
Abdominal signs
Distention Tenderness Feeding residuals/Ileus Emesis Abdominal wall
erythema Persistent localized
abdominal mass Ascites Bloody stools
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Radiographic features
Ileus Bowel wall edema Fixed-position loop Pneumatosis
(arrows) or portal venous air
Pneumoperitoneum
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Pneumatosis intestinalis
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Portal Venous Air
Portal venous air
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Pneumoperitoneum
Hypodensity of peritoneal cavity due to anterior air
In decubitus position, air rises to space between liver and body wall
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NEC Evaluation
CBC, Blood gas every 6-8 hrs until stable
AP and decub KUB every 6-8 hrs until stable
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Management
Medical treatment
NPO for 7-10 days after normal KUB Ampicillin, Gentamicin for 14 days Clindamycin or Flagyl if actual or impending perforation
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Surgical Management
Indications for surgical intervention:
Worsening clinical picture despite medical management
Increasing abdominal distention Persistent fixed loop on KUB Abdominal mass GI perforation Signs of full thickness necrosis
Peritonitis: Ascites, Abdominal wall erythema Persistent thrombocytopenia Refractory metabolic acidosis
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Retinopathy of prematurity(ROP)
formerly known asRetrolental Fibroplasia (RLF)
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ROP
Vascular retinopathy Develops only in incompletely vascularized
retinas of premature infants
Correlated with illness and hyperoxia Acidosis, Hypothermia, Shock, and Asphyxia
arrest vessel growth
Abnormal growth in recovery phase results in “pile up” of vessels
Ridge without forward growth Peaks ~40 weeks PMA
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International Classification of ROP
(ICROP) Zones (I, II, III)
Stages: I = line of demarcation II = elevated ridge of vessels III = extraretinal
neovascular-ization (ERNV) into vitreous
IV = partial retinal detachment
V = complete retinal detachment
Plus disease Inflammation and vessels
engorgement Higher risk of scarring and
retinal detachment
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ROP Screening
Dilated retinal exam at 31 weeks PMA (or 4 weeks chronologic age if born after 27 weeks of gestation)
Whom to screen? Who were born prior to 31 weeks of
gestation OR Who were born prior to 33 weeks of
gestation AND had unstable course
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ROP Treatment
Indications Zone 1 any plus disease Zone 1 stage III disease Zone 2 stage II or III and plus disease
Laser ablation of peripheral retina
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Finally!The cost of prematurity
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Neonatal Mortality Associated with Prematurity, USA (2003-2005)
Gestational Age Gestational Age (completed weeks)(completed weeks)
% Survival if admitted to % Survival if admitted to NICUNICU
2323 38-6638-66
2424 43-8143-81
2525 85-9285-92
2626 86-9386-93
27-3227-32 86-9886-98
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