GUIDELINE FOR THE CARE OF EXTREME PREMATURE INFANTS

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GUIDELINE FOR THE CARE OF EXTREME
PREMATURE INFANTS

• Dr. LUBIN DANIEL
• NEONATAL DEPARTMENT
• CHAIM SHIBA MEDICAL CENTER
• ISRAEL, 1998

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Objectives

• PREVENTION OF INTRAVENTRICULAR HEMORRHAGE,
  PERIVENTRICULAR LEUKOMALACIA AND PERMANENT
  NEURODEVELOPMENTAL DEFICITS.
  
• NEW MODES OF MECHANICAL VENTILATION IN
  RESPIRATORY DISTRESS SYNDROME
• PREVENTION OF MASSIVE BLOOD VOLUME
  TRANSFUSION
  
  
  
• EARLY MINIMAL ENTERAL FEEDING

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• THE ACUTE STAGE
• FIRST 72 HOURS
• THE STABLE STAGE
• FIRST 2 WEEKS
• THE LATE STAGE

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THE ACUTE STAGE

• INTRAVENTRICULAR HEMORRHAGE
• RESPIRATORY DISTRESS SYNDROME
• BLOOD PRESSURE STABILIZATION
• PATENT DUCTUS ARTERIOSUS
• FLUID AND METABOLIC BALANCE
• SKIN PROTECTION

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THE STABLE STAGE

• APNEA OF PREMATURITY
• MINIMAL ENTERAL FEEDING
• VESSEL ACCESS
• INFECTION CONTROL
• NECROTIZING ENTEROCOLITIS

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THE LATE STAGE

• BRONCHOPULMONARY DYSPLASIA
• RETINOPHATY OF PREMATURITY
• PERIVENTRICULAR LEUKOMALACIA
• OSTEOPENIA OF PREMATURITY

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THE ACUTE STAGE MANAGEMENT DURING 72 HOURS

• PREVENTIVE SURFACTANT
• CONVENTIONAL MECHANICAL VENTILATION
• HFV - INTERSTITIAL EMPHYSEMA
• MEAN BLOOD PRESSURE ABOVE 30torr
• INDOMETHACIN - IVH PROPHYLAXIS, PDA
• SEDATION
• ANTIBIOTICS, NO TAPES ON SKIN
• WATER TO AVOID HYPERNATREMIA
• GLUCOSE , CALCIUM AND INSULIN IF NEEDED
  (HYPERGLYCEMIA, HYPERKALEMIA)

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THE STABLE STAGE MANAGEMENT

• FIRST HEAD US (DAY 3)
• EXTUBATION (DAY 3-5), NASAL CPAP
• AMINOPHYLLINE, DOXOPRAM TREATMENT
• PARENTERAL NUTRITION
• THE UAC IS PLACED AT LOW POSITION OR
  REPLACED WITH A PERIPHERAL A .LINE
• UVC IS REPLACED WITH A PCCV LINE
• MINIMAL ENTERAL FEEDING (DAY 4 - 7)
• FULL FEEDING (DAY 14)

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THE LATE STAGEMANAGEMENT

• SECOND HEAD US ( 2- 3 WEEKS )
• FIRST EYE EXAMINATION AND THIRD HEAD US ( 4 -6
  WEEKS )

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INTRAVENTRICULAR HEMORRHAGE PATHOGENESIS AND
MANAGEMENT
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1. FLUCTUATING CEREBRAL BLOOD FLOW

• VENTILATED PRETERM INFANTS WITH RESPIRATORY
  DISTRESS SYNDROME
• PATENT DUCTUS ARTERIOSUS
• MANAGEMENT
• SYNCHRONIZED VENTILATION
• MUSCLE PARALYSIS
• SEDATION
• INDOMETHACIN

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2. INCREASE IN CEREBRAL BLOOD FLOW

• HYPERTENSION (PRESSURE-PASSIVE CIRCULATION)
• RAPID COLLOID INFUSION
• HYPEROSMOLAR SOLUTIONS
• HYPERCARBIA
• DECREASED HEMATOCRIT
• DECREASED BLOOD SUGAR
• TRACHEAL SUCTIONING

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3. INCREASE IN CEREBRAL VENOUS PRESSURE

• AIR LEAK SYNDROME
• VENOUS ANATOMY IN THE GERMINAL MATRIX
• HYPOXIC ISCHEMIC CARDIAC FAILURE
• LABOR AND DELIVERY ?

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4. DECREASE IN CEREBRAL BLOOD FLOW

• HYPOTENSION

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5. PLATELET AND COAGULATION DISTURBANCES

• FRESH FROZEN PLASMA
• VITAMIN K
• PLATELETS TRANSFUSION

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6. VASCULAR FACTORS

• FRAGILITY OF THE IMMATURE GERMINAL MATRIX
  MICROVASCULATURE
• INDOMETHACIN
• ANTENATAL CORTICOSTEROIDS
• ETHAMSYLATE?

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PREVENTION OF INTRAVENTRICULAR HEMORRHAGE -
POSTNATAL PHARMACOLOGIC INTERVENTION

• INDOMETHACIN
• DECREASES PRODUCTION OF THE VASODILATOR
  
• PROSTACYCLINE
• MATURATION OF THE GERMINAL MATRIX VESSELS
• CLOSING PATENT DUCTUS
• LOW PROPHYLACTIC DOSE LOWERS THE
• INCIDENCE OF THE MOST SEVERE FORMS
• PHENOBARBITAL ?
• ETHAMSYLATE ?
• VITAMIN K , VITAMIN E ?

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PERIVENTRICULAR LEUKOMALACIA

• ISCHEMIC LESION LEADING TO NECROSIS OF
  PERIVENTRIULAR WHITE MATTER
• 25 - 40 IN VLBW WHO DIE
• ONLY 30 - 40 WERE DETECTED BY US PRIOR
  TO DEATH
• INCIDENCE AMONG SURVIVING INFANTS 15?
• NO OPTIMUM TIME FOR DETECTION

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PERIVENTRICULAR LEUKOMALACIA PREVENTION

• AVOIDANCE OF
• HYPOXEMIA
• SYSTEMIC HYPOTENSION
• SEVERE HYPOCARBIA

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RESPIRATORY DISTRESS SYNDROME

• PREVENTIVE SURFACTANT
• SECOND SURFACTANT DOSE IF FIO2gt30
• CONVENTIONAL VENTILATION - NEW STRATEGIES
• HIGH FREQUENCY VENTILATION ?
• PARTIAL LIQUID VENTILATION ?
• NITRIC OXIDE ?

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RESPIRATORY DISTRESS SYNDROME

• CONVENTIONAL VENTILATION - NEW STRATEGIES
  PREVENTION OF ASYNCHRONY BETWEEN
  SPONTANEOUS AND VENTILATOR BREATHS.
• 1. PATIENT TRIGGERED VENTILATION
• 2. SYNCHRONIZED INTERMITTENT
• MANDATORY VENTILATION
• - BETTER OXYGENATION
• - REDUCED CEREBRAL BLOOD
  FLOW FLUCTUATIONS
• - LOWER MEAN PRESSURE
• - SHORTER MECHANICAL
  VENTILATION
• - DECREASED NEED FOR
  SEDATION
• - FEWER INFANTS WITH
  BPD

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RESPIRATORY DISTRESS SYNDROME

• LIQUID - ASSISTED VENTILATION ( LAV)
• PULMONARY GAS EXCHANGE SUPPORTED BY
  TRACHEAL INSTILLATION OF PERFLUOROCHEMICAL
  ( PFC) LIQUIDS
• PERFLUOROCHEMICALS (PFC)
• LOW SURFACE TENSION
• HIGH RESPIRATORY GAS SOLUBILITY
• BIOLOGICAL INERTNESS
• LAV TECHNIQUES
• TOTAL LIQUID VENTILATION
• PARTIAL LIQUID VENTILATION
• PFC LAVAGE

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RESPIRATORY DISTRESS SYNDROME

• PARTIAL LIQUID VENTILATION
• 30 cc/Kg PFC LIQUID
• 10 cc/Kg GAS
• IMPROVEMENT IN OXYGENATION
• CLINICAL IMPROVEMENT AND SURVIVAL IN SOME
  PATIENTS NOT EXPECTED TO SURVIVE
• 100 CENTERS IN THE USA HAVE RECEIVED
  APPROVAL TO PARTICIPATE IN CLINICAL TRIALS
  OF LAV

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RESPIRATORY DISTRESS SYNDROME

• HIGH FREQUENCY OSCILLATORY
• VENTILATION ( HFOV) AND RDS
• 9 PROSPECTIVE RANDOMIZED TRIALS
  REPORTED
• CONVINCING BENEFICIAL EFFECTS ON
• OXYGENATION AND VENTILATION
• REDUCE OCCURRENCE OF AIR LEAK SYN.
• TREATMENT OF CHOICE IN PULMONARY INTERSTITIAL
  EMPHYSEMA
• EFFECTS ON CEREBRAL CIRCULATION
• AND ON SURFACTANT REMAIN TO BE
• EVALUATED

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RESPIRATORY DISTRESS SYNDROME

• NITRIC OXIDE
• IMPROVE OXYGENATION IN SEVERE
• RDS WITH INTRACTABLE HYPOXEMIA

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MINIMAL ENTERAL FEEDING

• FEEDING VOLUME 0.1 - 4 cc/Kg/d
• STABLE PREMATURE INFANT
• AGE OF 3 - 6 DAYS
• NO INCREASE IN THE INCIDENCE OF NECROTIZING
  ENTEROCOLITIS

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MINIMAL ENTERAL FEEDING

• MUCOSAL EFFECTS
• TROPHIC EFFECT 2 TO 3 FOLD INCREASE
  IN MASS OF MUCOSA
• MUSCLE EFFECTS
• GREATER MIGRATING MOTOR ACTIVITY
• LESS FEEDING INTOLERANCE

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MINIMAL ENTERAL FEEDING

• VASCULAR EFFECTS
• POST PRANDIAL DECREASE IN
• SPLANCHNIC BED RESISTANCE
• INCREASED INTESTINAL BLOOD FLOW AND OXYGEN
  UPTAKE

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MINIMAL ENTERAL FEEDING

• ENDOCRINE EFFECTS
• ELEVATED CONCENTRATIONS OF
• GASTROINTESTINAL PEPTIDES
• GASTRIN, ENTEROGLUCAGON,
• MOTILIN, NEUROTENSIN,
• PANCREATIC POLYPEPTIDES

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RETINOPATHY OF PREMATURITY

• RISK FACTORS
• GESTATIONAL AGE
• SUPPLEMENTAL OXYGEN
• VITAMIN E DEFICIENCY
• INDOMETHACIN ?
• CORTICOSTEROIDS ?
• LIGHT LEVEL ?

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RETINOPATHY OF PREMATURITY

• TREATMENT
• 1. CRYOTHERAPY
• FREEZING THE AVASCULAR AREA
  ANTERIOR TO THE NEOVASCULAR RIDGE
• VASOGENIC FACTOR ?
• 2. LASER PHOTOCOAGULATION

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ERYTHROPOIETEN TO USE OR NOT TO USE ?

• 80 cc/Kg BLOOD
• BLOOD EXAM 15 CC/DAY IN THE ACUTE
• STAGE.
• HOW CAN WE REDUCE THE TOTAL
• BLOOD VOLUME TRANSFUSION?

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ERYTHROPOIETEN TO USE OR NOT TO USE ?

• ERYTHROPOIETEN ?
• OCTOPUS PACK OF 8 MINI UNITS ?
• DILATE CLAMPING OF UMBILICAL CORD?
• COMBINATION?
• STREAKED GUIDELINES FOR BLOOD TRANSFUSION

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ERYTHROPOIETEN TO USE OR NOT TO USE ?

• INCREASES ERYTHROPOIESIS retic, normoblasts,
  Hb.
• REDUCES IRON STORES
• REDUCES PMN
• INCREASE HBF

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ERYTHROPOIETEN TO USE OR NOT TO USE ?

• REDUCES TRANSFUSION REQUIREMENTS IN SPECIFIC
  GROUPS OF BABIES
• ALL INFANTS lt 28 WK
• INFANTS 28 - 32 WK lt 3rd CENTILE
• STANDARD DOSE 750 U/Kg/week - END OF FIRST
  WEEK.
• HIGH DOSE FOR SICK BABIES (MV 1.2CC)
• 1400U/Kg/week - 72 HOURS

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ERYTHROPOIETEN TO USE OR NOT TO USE ?

• NEJM 500 - 750 GR 33 REDUCTION
• BJCD 600 GRlt 4.7 7.5 BT. VOL
• HAMMERSMITH 2.8 5.8 BT. / 31 87 VOL
• SICK 6.8 7.8 BT / 72 68
  VOL

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ERYTHROPOIETEN TO USE OR NOT TO USE ? OCTOPUS

• SINGLE DONOR
• 4-6 WEEKS / 8 MINI UNITS

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ERYTHROPOIETEN TO USE OR NOT TO USE ? DELAYED
CORD CLAMPING

• BMJ 306, 172 93
• 27 - 32 WK 1 -2 Kg
• 15 minutes NO BLOO TRANSFUSION

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ERYTHROPOIETEN TO USE OR NOT TO USE ? STRICT
GUIDELINES

• NO NEED FOR TRANSFUSION IN 60
• OF VLBW INFANTS
• MEAN 5 TRANSFUSIONS