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The Very Low Birth Weight Infant
Dana Rivera, M.D.
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Delivery
A 800 gram female infant at 26 weeks
Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption
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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
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ETT size selection– < 1kg: 2.5– 1-2 kg: 3.0– 2-3 kg: 3.5– > 3 kg: 4
Position?– between clavicles
and carina
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Umbilical lines?
UVC– Intrathoracic IVC
– Just above diaphragm UAC
– High: T6-9, T7-10
– Low: below L3
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Initial Hours
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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Surfactant Deficiency SyndromeSigns and Symptoms
Respiratory distress– tachypnea– grunting – retractions – flaring– coarse breath sounds– mixed acidosis– hypoxia
CxR:
ground glass
underinflation
air bronchograms
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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
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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
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Surfactant Deficiency SyndromeManagement
Prevention Respiratory support Surfactant replacement
– Side effects
Antibiotics Maintain Hct
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Day # 2
NPO, placed on IVF or TPN??
Total fluid goal greater or less than term infant?? Why?
Determining ongoing fluid needs??
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Day #4
Increased ventilator support overnight
ABG: 7.22/50/50/16/-7
Murmur
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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Patent Ductus ArteriosusSigns and Symptoms
Murmur Widened pulse pressure Hyperactive precordium Bounding pulses Metabolic acidosis
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PDA- Pathophysiology
LR shunt– Pulmonary congestion– L-sided overload– CHF
Diagnosis– ECHO
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PDA- Management
– MedicalFluid restrictionDiureticsIndomethacin
– Contraindications
– SurgicalMedical failureCritical statusContraindication to indomethacin
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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?
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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Apnea of Prematurity
Cessation of breathing > 15 sec duration with desaturation/ bradycardia
Central, obstructive, mixed
Methylxanthine tx– Caffeine
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Caffeine
Stimulates medullary respiratory center
Increased sensitivity to CO2
Enhanced diaphragmatic contractility
Diuretic
Enhanced catecholamine response
– Increased cardiac output/ HR
Increased glucose (glycogenolysis)
GER
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Day #7
What is the one test you should order today??
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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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%
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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
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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
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Day #14
2 spits yesterday of small amount of formula
10cc bilious residual this am on premature formula (16cc q3hr)
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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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
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NEC- radiograph
Pneumatosis intestinalis
thickened bowel wall
sentinel loop
“soap bubble” appearance (RLQ)
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NEC
Pneumoperitoneum
Portal venous air
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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
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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
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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
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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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
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BPD- Pathophysiology
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Day #38
What should have been ordered by now??
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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Retinopathy of prematurity (ROP)
Risk factors?– Prematurity, oxygen exposure
Vasoconstriction vaso-obliteration neovascularization
Classification– Stages 1-5– Zones I-III
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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
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ROP screening
< 1500gm or 32 weeks
Selected infants >1500gm, > 32 weeks
AAP policy statement– Pediatrics 117(2), 2/06
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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
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Who is the most famous person affected by ROP?
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