nonimmune hydrops geetha b. thippeswamy, md august 16 th 2002
TRANSCRIPT
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NONIMMUNE HYDROPS
Geetha B. Thippeswamy, MD
August 16th 2002
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Neonatal presentation
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Transition of hydropic babies to extrauterine life
Understanding this is very important in planning the resuscitation of the hydropic newborn
Hydropic babies often display signs of intrapartum asphyxia at birth
No respiratory effort or have a poor effort.
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Transition of hydropic babies to extrauterine life
Decreased respiratory compliance and increased resistance:
1. Airway edema2. Chest wall edema3. Pulmonary edema4. RDS5. Pleural effusion, 6. Ascites 7. Pulmonary hypoplasia
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Transition of hydropic babies to extrauterine life
Hypoxia and acidosis sec to gas exchange compromise.
Hypoxia decreases cardiac function. PPHN sec to hypoxia. PPHN worsens vent perfusion matching and
hypoxemia that is minimally responsive to supplemental oxygen.
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Things to do when consulted
Review antepartum and intrapartum history 1. Maternal history 2. Past obstetric history 3. Present pregnancy history 4. Diagnostic evaluations 5. Labor
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Counsel parents
Meet with parents before delivery. Explain in the language they understand. Inform them about the fetal condition and
the prognosis. Explain the delivery room resuscitation and
potential procedures to be performed. Genetic consult.
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Delivery and resuscitation
Hydropic babies should be delivered in Tertiary care centers.
Coordinated and aggressive delivery room resuscitation is very important.
Personnel and equipment required for resuscitation exceeds the general Neonatal resuscitation recommendations of AAP and AHA.
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Resuscitation team
Size of the resuscitation team is considerably larger.
Six to seven people with a variety of tasks assigned form the team and will be present in the delivery room.
An experienced neonatologist should orchestrate all resuscitation activities.
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Resuscitation team responsibilities
Airway/ventilation Circulation Catheters Equipment and medications Data recording Runner
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Delivery room and Equipment
Temperature control.
1. Delivery room temp should be at least 75º F
2. Turn overhead warmer to full heater output
3. Clear plastic bag to cover the infant
4. Skin thermistor
5. Warm dry cap
6. Preheat oxygen to be used to 93º to 97ºF
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Airway/Ventilation
Endotracheal tube of different sizes Flow inflating bags Flow of heated humidified oxygen at 5 to 8
L/min
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Catheters
Prepare for umbilical artery and umbilical vein catheterization.
Transducers for arterial and venous pressure monitoring.
Equipment for drawing and transporting blood gases.
A sterile tray for paracentesis, thoracentesis.
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Other..
Blood: O neg, PRBCs cross matched against mother’s blood.
Cardio respiratory monitor. Pulse ox monitor. Portable radiography equipment. Defibrillator or equipment for ventricular
pacing.
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Delivery room protocol
Avoid cold stress.1. Position infant under warmer with
servocontrol set to 96º to 98º F.2. Briefly dry and place a cap on the head.3. Cover infant with the clear plastic,
procedures performed by tearing small holes.
4. CR and pulse ox monitors attached.
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Airway/Ventilation
Respiratory efforts are depressed or ineffective.
Suction the mouth and nose. Tracheal suctioning if amniotic fluid is meconium stained.
Bag and mask ventilation is extremely difficult.
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Airway/Ventilation
IMMEDIATE INTUBATION IS RECOMMENDED in all hydropic infants.
Depth of ET tube insertion based on position of the tube at the vocal cords and symmetry of breath sounds on auscultation.
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Airway/Ventilation
Positive pressure ventilation is initiated using peak pressures.
Pressures used should provide sufficient tidal volume.
Tidal volume is assessed by chest wall motion and breath sounds.
Surfactant administered in premature infants.
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Vascular Access
Place UVC and UAC. Attach pressure transducers. Obtain blood sample for blood gas and
hematocrit analysis. Infuse glucose at 8 to 10 mg/kg/min to
avoid hypoglycemia. A-P radiograph obtained to confirm ET
tube and catheter placement.
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Monitor
Continuously monitor success of resuscitation by assessing,
1. Adequate breath sounds
2. Heart rate
3. Oxygen saturation If the response is suboptimal, consider
abdominal paracentesis.
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Abdominal paracentesis
This improves cardiac and respiratory functions.
Just remove enough fluid to improve chest wall motion.
Excess fluid removal could precipitate hypovolemic shock.
18 to 20 gauge iv catheter with stylet is preferred.
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Thoracentesis
Proceed to thoracentesis if the response to paracentesis is suboptimal.
Thoracentesis helps only in the presence of normal lungs.
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Thoracentesis
Thoracentesis may not be helpful if lung compliance is decreased as in,
1. Pulmonary hypoplasia sec to large and long standing effusion is present.
2. Lung is surfactant deficient.3. Pulmonary edema Pneumothorax in the presence of pulmonary
hypoplasia.
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Transfer to ICN
Infants are transferred to ICN only when they are,
1. Stable
2. ET tube and the catheters have been secured.
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ICN management
Respiratory: Mechanical ventilation. HFOV and NO therapy may be needed
Chest tubes for persistent pleural effusion.
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ICN management
Fluid and Electrolytes: Primary goal is resolution of hydrops.
Maintenance fluids should be restricted. Bolus fluids for inadequate intravascular
volume. Avoid sodium initially.
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ICN management
Fluids and electrolytes cont.. Initiate diuresis with 25% albumin or
diuretics. Albumin infused only if CVP is low or
normal. Diuretics given only when CVP is high.
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ICN management
Fluid and electrolyte administration guided by monitoring:
1. Urine and serum sodium levels
2. Strict daily I/O
3. Daily weights Most of these infants loose 15 to 30% of
their body weight.
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ICN management
Cardiovascular: Shock sec to hypovolemia. Maintain adequate intravascular volume. Ionotropic support.
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ICN management
Hyperbilirubinemia: in anemic infants. Develops within 30 to 60 mins after birth. Phototherapy and exchange transfusion
based on bilirubin levels. Anemia: PRBC transfusion or partial
exchange transfusion.
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ICN management
Supportive care as appropriate, especially for the premature infants.
Evaluation of the newborn if cause of NIH is not known.
Specific therapy based on underlying etiology of NIHF when possible.
Asses parental needs and encourage them to participate in the care.
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Evaluation of NIH infant with unknown cause
CVS: Echo and electrocardiogram Pulm: CXR, pleural fluid analysis Hemat: cord blood studies and PBS GI:U/S of abdomen, LFTs, peritoneal fluid
analysis.
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Evaluation of NIH infant with unknown cause
Renal: UA, BUN, Cr. Genetic: Chromosomal analysis, skeletal
radiographs, genetic consultation. Cong infections: Viral cultures or serology Pathologic: Placental examination,
autopsy(in case of neonatal death)
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NIHF Prognosis
Prognosis is very poor with high rate of morbidity and mortality
Perinatal mortality: 50 to 90% 50% of cases diagnosed in utero result in
fetal death. 50% of all live born infants die.
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NIHF prognosis
Idiopathic variety have the best prognosis. Good prognosis with:
1. Anemia that can be treated in utero or in newborn period; >90% survive.
2. Isolated arrhythmia ; > 50% survive.
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NIHF prognosis
Poor prognosis associated with:
1. Prematurity
2. Pleural effusion with pulmonary hypoplasia.
3. Chromosomal disorders
4. Structural malformations.
5. Severe hydrops.
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Thank you