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8/13/2019 V Lbw Update
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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 gradualincrease in HR
Transferred to NICU
Perfusion remains poor with pallor
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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 Syndrome
Signs and Symptoms
Respiratory distress
tachypnea
grunting
retractions
flaring
coarse breath sounds
mixed acidosis
hypoxia
CxR:
ground glassunderinf lat ion
ai r bronchograms
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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
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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
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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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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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Patent Ductus Arteriosus
Signs 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
Medical
Fluid restriction
Diuretics
Indomethacin
Contraindications
Surgical
Medical failure
Critical status
Contraindication 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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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%
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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
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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
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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 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
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NEC- radiograph
Pneumatosis
intest inal is
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?
Mult i factor ial
GI dysmotility/ stasis
Partially digested formula
substrate for bacterial
proliferation
Mucosal injury/ bacterialinvasion
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 necroticbowel with ostomy
Peritoneal drain
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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
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Diagnosis
BPD
IVH
PDA
ROP
ROS
SDS
AOP
NEC
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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
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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
Vasoconstrictionvaso-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 retinaldetachment
Plus disease Tortuous arterioles,
dilated venules Higher stage, lower zone-
worse disease state
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ROP screening
< 1500gm or 32 weeks
Selected infants
>1500gm, > 32 weeks
AAP policy statement
Pediatrics117(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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