v lbw update

8/13/2019 V Lbw Update

1/46

The Very Low Birth Weight Infant

Dana Rivera, M.D.


2/46

Delivery

A 800 gram female

infant at 26 weeks

Precipitous vaginal

delivery to 22 yr old

G3P1 with suspected

placental abruption


3/46

Resuscitation

Baby pale, no respiratory effort, HR 60

Requires intubation with PPV with gradualincrease in HR

Transferred to NICU

Perfusion remains poor with pallor


4/46


5/46

Umbilical lines?

UVC

Intrathoracic IVC

Just above diaphragm

UAC

High:

T6-9, T7-10

Low:

below L3


6/46

Initial Hours


7/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


8/46

Surfactant Deficiency Syndrome

Signs and Symptoms

Respiratory distress

tachypnea

grunting

retractions

flaring

coarse breath sounds

mixed acidosis

hypoxia

CxR:

ground glassunderinf lat ion

ai r bronchograms


9/46

Surfactant Deficiency Syndrome

Physiology

Made by?

Type II pneumocytes

Detected by? ~23 weeks, inadequate until ~32 weeks

Made of? 70-80% phospholipids

Works by? Prevents high surfacetension


10/46

Laplaces Law

Pressure = 2x tension/radius

If surface tension equalsmaller alveolus emptiesinto larger alveolus

Surface tension of

different sized alveoli notconstant- smaller alveolihave lower surfacetension


11/46


12/46

Day # 2

NPO, placed on IVF or

TPN??

Total fluid goal greater or

less than term infant??

Why?

Determining ongoing

fluid needs??


13/46


14/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


15/46

Patent Ductus Arteriosus

Signs and Symptoms

Murmur

Widened pulse pressure Hyperactive precordium

Bounding pulses

Metabolic acidosis


16/46

PDA- Pathophysiology

LR shunt Pulmonary congestion

L-sided overload

CHF

Diagnosis

ECHO


17/46

PDA- Management

Medical

Fluid restriction

Diuretics

Indomethacin

Contraindications

Surgical

Medical failure

Critical status

Contraindication to indomethacin


18/46

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?


19/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


20/46

Apnea of Prematurity

Cessation of breathing >

15 sec duration with

desaturation/bradycardia

Central, obstructive,

mixed

Methylxanthine tx Caffeine


21/46

Caffeine

Stimulates medullary

respiratory center

Increased sensitivity to

CO2

Enhanced diaphragmatic

contractility

Diuretic

Enhanced

catecholamine response

Increased cardiac output/

HR

Increased glucose

(glycogenolysis)

GER


22/46

Day #7

What is the one test you should order today??


23/46


24/46

Intraventricular Hemorrhage

Signs and Symptoms

Catastrophic

bulging fontanelle

posturing

seizures

apnea

hypotension

metabolic acidosis drop in Hct

death

Saltatory

Cycle of deterioration and

recovery

Silent: 50%


25/46

Intraventricular hemorrhage (IVH)

Pathophysiology

Germinal matrix Developmental area of

brain

Periventricular b/wcaudate nucleus andthalamus

Provides neurons/ glial

cells

Richly vascularized/ loosesupportive stroma

Dissipates by term

Poor control of cerebral

b lood f low


26/46


27/46

IVH

Grade I

Germinal matrix only

(subependymal) Grade II

Intraventricular/ normalventricles

Grade III

IVH + dilated ventricles

Grade IV

IVH + parenchymal bleed

Screening head u/s

< ~34 weeks

Management

Supportive,

ventricular taps,

reservoirs, VP shunts

Prognosis


28/46

Day #14

2 spits yesterday of

small amount of formula

10cc bilious residual this

am on premature

formula (16cc q3hr)


29/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


30/46

NEC- Signs and Symptoms

Abdominal

distension, tenderness,

discoloration, mass

Feeding into lerance

Vomiting (bilious), gastric

residuals, heme (+)/

bloody stools

Systemic

Lethargy, apnea, poor

perfusion, temp instability

Labs

ref lect sepsis

leukocytosis/ leukopenia,

L shift

thrombocytopenia

acidosis

hypo/hyperglycemia hypoxia/hypercapnea


31/46

NEC- radiograph

Pneumatosis

intest inal is

thickened bowel wall

sentinel loop

soap bubble

appearance (RLQ)


32/46

NEC

Pneumoperitoneum

Portal venous air


33/46

NEC- Pathophysiology

Onset?

3-10 days (24hr-

3mo)

Where?

Jejunum, ileum, colon

What? Bowel necrosis,

edema, hemorrhage,

perforation

Etiology?

Mult i factor ial

GI dysmotility/ stasis

Partially digested formula

substrate for bacterial

proliferation

Mucosal injury/ bacterialinvasion

Mesenteric ischemia

Inflammatory mediators


34/46

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 necroticbowel with ostomy

Peritoneal drain


35/46

Day # 38

S/P NEC, no perforation,

feedings resumed after

10 days bowel rest withelemental formula,

reached full feeds 4 days

ago

Now extubated, remainsoxygen dependent


36/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


37/46

Chronic lung disease (CLD or BPD)

Treatmentwith oxygen >21% for at least 28 days plus

Mild BPD:

Breathing room air at 36 weeks postmenstrual age(PMA) or discharge

ModerateBPD:Need for


38/46

BPD- Pathophysiology


39/46

Day #38

What should have been ordered by now??


40/46

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC


41/46

Retinopathy of prematurity (ROP)

Risk factors?

Prematurity, oxygen exposure

Vasoconstrictionvaso-obliteration

neovascularization

Classification

Stages 1-5

Zones I-III


42/46

ROP- Stages & Zones

1: Demarcation line

2: Ridge formation

3: Neovasculariztion/proliferation

4: Partial retinal detachment

5: Complete retinaldetachment

Plus disease Tortuous arterioles,

dilated venules Higher stage, lower zone-

worse disease state


43/46

ROP screening

< 1500gm or 32 weeks

Selected infants

>1500gm, > 32 weeks

AAP policy statement

Pediatrics117(2), 2/06


44/46

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


45/46

Who is the most famous person

affected by ROP?


46/46

v lbw update

Documents