neonatal cold injury syndrome
DESCRIPTION
TRANSCRIPT
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Neonatal Cold Injury Syndrome (sclerema neonatorum)
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Objectives
What will I learn?
Etiologies and pathophysiology
Symptoms
Diagnosis
Treatment
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Definition
-- mainly caused by cold stress
--the clinical features are low body
temperature and scleredema
--serious one may appear multiple organ
dysfunction.
Scleredema --- hardening of the skin and subcutaneous tissue
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Etiology and pathophysiology
Characteristics of temperature regulation
and subcutaneous fatty composition in
newborn
● immaturity of temperature regulation
center
● relative large surface area and rich
blood flow cause poor thermal insulation
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● limited storage of energy, heat production
mainly by brown fatty metabolism,
lacking shivery thermogenesis
● more quantity of saturated fatty acid with
higher melting point
Imbalance between heat production and loss
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Distribution of neonatal brown fat
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Cold injury
● Cold environment increase heat loss, low body
temperature causes constriction of peripheral
blood vessels, dysfunction of microcirculation
● Low body temperature and cold environment
cause anoxia, metabolic disturbance and
acidosis even multiple organ dysfunction (MOD)
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Other Factors
● severe infection,
● premature,
● asphyxia, ICH,
● erythroblastosis
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Imbalance between heat production and loss
Heat production Heat production Heat production Heat production
cold
√
asphyxiaNon-enough Non-enough intakeintake
√
infection
√ √
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Imbalance between heat production and loss
Heat loss Heat loss Heat loss Heat loss
cold
√
relative larger surface
√
coldcold
√
immature of temperature
center
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immature of temperature center
relative larger surface cold 、 non-enough intake
infection 、 asphyxia
heat production
of brown fat↓
anoxia, acidosis
higher saturated fatty acid
higher melt point
body temperature ↓
coagulation of subcutaneous fat
Pathogenesis of Neonatal Scleredema
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Anoxia, acidosis coagulation of subcutaneous fat
constriction of skin vessels
anoxia of tissue
hardening of skin
Slowly blood flow
disturbance of microcirculation
capillary permeability ↑
edema circulating volume↓
shock
multiple organs dysfunction
DIC
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● usually occur in cold season
● during first 3 days or any time in preterm infants
● Low body temperature
● Scleredema
● MOD in severe case
Clinical Manifestations
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● feature: skin and subcutaneous tissue
become indurated, woody, non-pitting,
cold to touch, involved area may with
edema, redness, cyanosis; symmetrical
● Sequence: calves→thighs→low
extremities→buttock→cheeks→upper
extremities→whole body
Scleredema
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Neonatal scleredema
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multiple organ dysfunction
● bradycardia, dyspnea,
● microcirculation disturbance,
● shock, DIC,
● acute renal failure,
● pulmonary hemorrhage
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Evaluation of body surface area
Head and neck 20%
Upper limbs 18%
Anterior part of trunk 14%
Posterior part of trunk 14%
Buttock 8%
Lower limbs 26%
20%
9% 9%14% 14%
8%
13% 13%
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Degrees of NCIS
Body temperature( ) involved area change of ℃organic
anus T axil – anus T (% 、 color) function
I0 ≥ 35 positive < 20 no change
(mild) pale
II0 < 35 0 or positive 20 ~ 50 poor reaction
(moderate) dark red bradycardia
III0 < 35 negative > 50 shock 、 DIC 、
(severe) or < 30 cyanotic PH or ARF
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nonspecific examination for diagnosis.
blood gas analysis, CT, PT,
blood glucose level, platelet,
electrolytes, BUN,
fibrogen, etc.
EKG, X - ray
Laboratory Examination
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Differential diagnosis
Neonatal edema● Localized edema
● Premature infant edema
--hypoalbuminemia, hyponatremia
● Hemolytic disease of newborns
- anemia, splenohepatomegaly or Jaundice
● Congenital nephrosis
-abnormal in urine
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Neonatal edema
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Differential diagnosis
Subcutaneous gangrene - staphylococcus aureus
-compressive site or impaired site
-swelling, blush, hard
-darkening, bleed, ulcer
-obscure boundary
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Neonatal Subcutaneous Gangrene
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treatment
Heat loss
Heat production
Correction of organ dysfunction
normal body temperature organs function
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Treatment
● Restoration of body temperature
● Energy supply and fluid infusion
● Correction of organ dysfunction
· correction of acidosis and volume expansion
· treatment of pulmonary hemorrhage
· arrangement of ARF and DIC
● Others: antibiotics, symtomatic therapy
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Treatment
Rewarming
● TR >30 , TA-R≥0℃
--Placed in a neutral thermal
environment
--Returned to normal temperature
during 6~12 hours
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Treatment
● TR < 30 , ℃ TA-R<0
• Placed in a incubator where environmental
temperature higher 1~2 than body ℃
temperature( 0.5-1 /h℃ )
• Kept in a neutral thermal environment when
TR ≥ 35 ℃
• Returned to normal temperature during
12~24 hours
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Treatment
Ways of re-warming
● Incubator
● Open radiant warmer bed
● Others
water bath, electric blanket ,
Kangaroo Care, etc
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Incubator
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Open radiant warmer bed
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Huge omphalocele( 巨大脐膨出)
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Prevention
● Neonatal care:
warm environment, enough clothes
● Encourage early breast feeding
● Prevent high risk factors:
premature, infection, asphyxia
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Conclusion and Review
● How to diagnose neonatal sepsis?
● Which marker can indicate neonatal
infection?
● How many factors can cause NCIS?
● Which complication is caused by NCIS?
● State the clinic S/S and degrees of NCIS.
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Mini case discussion
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Clinical case presentation
• Patient1:10.09.06
• Sex: male
• GA:32+2W
• BW:1240g
• Vaginal delivery Apgar:8-10-10
• Umbilical pH:7.22
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PROM of 2days
intrapartum ampicillin because of PROM(pre-
rupture of membrane ) and maternal elevation of
CRP
Admitted to NICU duo to prematurity
General condition is unstable
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• Frequent apnea 2 hrs after birth,
aminophyllin and CPAP ( continuous positive airway
pressure ) was given for 3 days and apnea
disappeared.
• Because of VLBW, umbilical venous
catheterization was performed on D1 and the
catheter was removed on D7. PICC ( peri-
intravenous central-line catheterization ) was inserted
on D7.
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• The general condition was stable after D3
except poor enteral feeding.
• On postnatal D13, he was getting worse :
tachypnea, tachycardia, pale, grunting ,
abdominal distention, cyanosis, low BP
and hypothemia.
--antibiotics , IVIG, CPAP was given.
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23/4/8 49
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Questions
• What kinds of diseases did the baby
suffer? Predisposing factor?
• What kinds of Lab tests would you
order?
• How can you save his life?
• How about his prognosis?
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Septic work-ups
• Complete Blood Count
• Blood & Urine cultures
• Lumbar Puncture
• Chest X-Ray
• Line cultures
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< 2 abnormal values & culture negative
Treat for 48 hours,(regardless of maternaltreatment) & dischargehome when appropriate
Culture + orLP abnormal
Culture - &LP normal
Treat for 7-10 daysfor bacteremia &14-21 days for
meningitis
Treat for 48 hrs. iflow suspicion of
sepsis & nopretreatment
Begin antibiotics
Evaluation of Symptomatic Infants for Neonatal Sepsis
> 2 abnormal values
= ~12hrs**WBC/Diff & CRP
Blood cultureChest x-ray
lumbarpuncture
Treat for 7-10 daysif high suspicion ofsepsis or mother
pretreated
Infant appears well & symptoms resolve
Treat for 7-10 days ifhigh suspicion of
sepsis