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The Very Low Birth Weight Infant

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The Very Low Birth Weight Infant
Dana Rivera, M.D.
Delivery
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A 800 gram female
infant at 26 weeks
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Precipitous vaginal
delivery to 22 yr old
G3P1 with suspected
placental abruption
Resuscitation
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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
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Position?
–
between clavicles
and carina
Umbilical lines?
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UVC
–
Intrathoracic IVC
–
Just above diaphragm
UAC
–
High:
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–
T6-9, T7-10
Low:
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below L3
Initial Hours
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Surfactant Deficiency Syndrome
Signs and Symptoms
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Respiratory distress
– tachypnea
– grunting
– retractions
– flaring
– coarse breath sounds
– mixed acidosis
– hypoxia
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CxR:
ground glass
underinflation
air bronchograms
Surfactant Deficiency Syndrome
Physiology
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Made by?
–
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Detected by?
–
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~23 weeks, inadequate until ~32 weeks
Made of?
–
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Type II pneumocytes
70-80% phospholipids
Works by?
–
Prevents high surface tension
Laplace’s Law
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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
Surfactant Deficiency Syndrome
Management
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Prevention
Respiratory support
Surfactant replacement
–
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Side effects
Antibiotics
Maintain Hct
Day # 2
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NPO, placed on IVF or
TPN??
Total fluid goal greater or
less than term infant??
Why?
Determining ongoing
fluid needs??
Day #4
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Increased ventilator
support overnight
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ABG: 7.22/50/50/16/-7
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Murmur
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Patent Ductus Arteriosus
Signs and Symptoms
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Murmur
Widened pulse pressure
Hyperactive precordium
Bounding pulses
Metabolic acidosis
PDA- Pathophysiology
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Lпѓ R shunt
–
–
–
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Pulmonary congestion
L-sided overload
CHF
Diagnosis
–
ECHO
PDA- Management
–
Medical
пЃ¬ Fluid restriction
пЃ¬ Diuretics
пЃ¬ Indomethacin
– Contraindications
–
Surgical
пЃ¬ Medical failure
пЃ¬ Critical status
пЃ¬ Contraindication to indomethacin
Day #6
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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?
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Apnea of Prematurity
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Cessation of breathing >
15 sec duration with
desaturation/
bradycardia
Central, obstructive,
mixed
Methylxanthine tx
–
Caffeine
Caffeine
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Stimulates medullary
respiratory center
Increased sensitivity to
CO2
Enhanced diaphragmatic
contractility
Diuretic
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Enhanced
catecholamine response
–
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Increased cardiac output/
HR
Increased glucose
(glycogenolysis)
GER
Day #7
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What is the one test you should order today??
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Intraventricular Hemorrhage
Signs and Symptoms
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Catastrophic
–
–
–
–
–
–
–
–
bulging fontanelle
posturing
seizures
apnea
hypotension
metabolic acidosis
drop in Hct
death
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Saltatory
–
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Cycle of deterioration and
recovery
Silent: 50%
Intraventricular hemorrhage (IVH)
Pathophysiology
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Germinal matrix
–
Developmental area of
brain
–
Provides neurons/ glial
cells
–
Periventricular b/w
caudate nucleus and
thalamus
–
Richly vascularized/ loose
supportive stroma
–
Dissipates by term
–
Poor control of cerebral
blood flow
IVH
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Grade I
–
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Intraventricular/ normal
ventricles
Grade III
–
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Germinal matrix only
(subependymal)
Grade II
–
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IVH + dilated ventricles
Grade IV
–
IVH + parenchymal bleed
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Screening head u/s
– < ~34 weeks
Management
– Supportive,
ventricular taps,
reservoirs, VP shunts
Prognosis
Day #14
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2 spits yesterday of
small amount of formula
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10cc bilious residual this
am on premature
formula (16cc q3hr)
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
NEC- Signs and Symptoms
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Abdominal
–
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Feeding intolerance
–
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distension, tenderness,
discoloration, mass
Vomiting (bilious), gastric
residuals, heme (+)/
bloody stools
Systemic
–
Lethargy, apnea, poor
perfusion, temp instability
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Labs
–
–
–
–
–
–
–
reflect sepsis
leukocytosis/ leukopenia,
L shift
thrombocytopenia
acidosis
hypo/hyperglycemia
hypoxia/hypercapnea
NEC- radiograph
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Pneumatosis
intestinalis
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thickened bowel wall
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sentinel loop
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“soap bubble”
appearance (RLQ)
NEC
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Pneumoperitoneum
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Portal venous air
NEC- Pathophysiology
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Onset?
–
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Where?
–
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3-10 days (24hr3mo)
Etiology?
–
Multifactorial
–
GI dysmotility/ stasis
Partially digested formula
substrate for bacterial
proliferation
Mucosal injury/ bacterial
invasion
Mesenteric ischemia
Inflammatory mediators
–
Jejunum, ileum, colon
What?
–
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Bowel necrosis,
edema, hemorrhage,
perforation
–
–
–
NEC- Management
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Medical
–
–
–
–
–
–
–
–
Bowel rest
Decompression
Broad spectrum Abx
Serial radiographs
Fluid/ nutritional support
Blood product support
BP support
Respiratory/metabolic
support
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Surgical
–
–
–
Pneumoperitoneum, fixed
abdominal mass,
persistently dilated loop,
abdominal discoloration,
persistent clinical
deterioration
Resection of necrotic
bowel with ostomy
Peritoneal drain
Day # 38
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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
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Chronic lung disease (CLD or BPD)
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Treatment with oxygen >21% for at least 28 days plus—
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Mild BPD: Breathing room air at 36 weeks postmenstrual age
(PMA) or discharge
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Moderate BPD: Need for <30% oxygen at 36 weeks PMA or
discharge
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Severe BPD: Need for 30% oxygen and/or positive pressure
(ventilation or continuous positive airway pressure) at 36 weeks
PMA
BPD- Pathophysiology
Day #38
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What should have been ordered by now??
Diagnosis
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BPD
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ROS
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IVH
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SDS
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PDA
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AOP
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ROP
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NEC
Retinopathy of prematurity (ROP)
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Risk factors?
–
Prematurity, oxygen exposure
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Vasoconstrictionпѓ vaso-obliterationпѓ neovascularization
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Classification
–
–
Stages 1-5
Zones I-III
ROP- Stages & Zones
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1: Demarcation line
2: Ridge formation
3: Neovasculariztion/
proliferation
4: Partial retinal detachment
5: Complete retinal
detachment
Plus disease
–
Tortuous arterioles,
dilated venules
Higher stage, lower zoneworse disease state
ROP screening
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< 1500gm or 32 weeks
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Selected infants
>1500gm, > 32 weeks
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AAP policy statement
–
Pediatrics 117(2), 2/06
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
Who is the most famous person
affected by ROP?
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