The Very Low Birth Weight Infant

1
The Very Low Birth Weight Infant

• Dana Rivera, M.D.

2
Delivery

• A 800 gram female infant at 26 weeks
• Precipitous vaginal delivery to 22 yr old G3P1
  with suspected placental abruption

3
Resuscitation

• Baby pale, no respiratory effort, HR 60
• Requires intubation with PPV with gradual
  increase in HR
• Transferred to NICU
• Perfusion remains poor with pallor

4

• ETT size selection
• lt 1kg 2.5
• 1-2 kg 3.0
• 2-3 kg 3.5
• gt 3 kg 4

• Position?
• between clavicles and carina

5
Umbilical lines?

• UVC
• Intrathoracic IVC
• Just above diaphragm
• UAC
• High
• T6-9, T7-10
• Low
• below L3

6
Initial Hours
7
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

8
Surfactant Deficiency SyndromeSigns and Symptoms

• Respiratory distress
• tachypnea
• grunting
• retractions
• flaring
• coarse breath sounds
• mixed acidosis
• hypoxia

• CxR
• ground glass
• underinflation
• air bronchograms

9
Surfactant Deficiency SyndromePhysiology

• Made by?
• Type II pneumocytes
• Detected by?
• 23 weeks, inadequate until 32 weeks
• Made of?
• 70-80 phospholipids
• Works by?
• Prevents high surface tension

10
Laplaces Law

• 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

11
Surfactant Deficiency SyndromeManagement

• Prevention
• Respiratory support
• Surfactant replacement
• Side effects
• Antibiotics
• Maintain Hct

12
Day 2

• NPO, placed on IVF or TPN??
• Total fluid goal greater or less than term
  infant?? Why?
• Determining ongoing fluid needs??

13
Day 4

• Increased ventilator support overnight
• ABG 7.22/50/50/16/-7
• Murmur

14
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

15
Patent Ductus ArteriosusSigns and Symptoms

• Murmur
• Widened pulse pressure
• Hyperactive precordium
• Bounding pulses
• Metabolic acidosis

16
PDA- Pathophysiology

• L?R shunt
• Pulmonary congestion
• L-sided overload
• CHF
• Diagnosis
• ECHO

17
PDA- Management

• Medical
• Fluid restriction
• Diuretics
• Indomethacin
• Contraindications
• Surgical
• Medical failure
• Critical status
• Contraindication to indomethacin

18
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
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

20
Apnea of Prematurity

• Cessation of breathing gt 15 sec duration with
  desaturation/ bradycardia
• Central, obstructive, mixed
• Methylxanthine tx
• Caffeine

21
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
Day 7

• What is the one test you should order today??

23
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

24
Intraventricular HemorrhageSigns and Symptoms

• Catastrophic
• bulging fontanelle
• posturing
• seizures
• apnea
• hypotension
• metabolic acidosis
• drop in Hct
• death

• Saltatory
• Cycle of deterioration and recovery
• Silent 50

25
Intraventricular hemorrhage (IVH)Pathophysiology

• Germinal matrix
• Developmental area of brain
• Periventricular b/w caudate nucleus and thalamus

• Provides neurons/ glial cells
• Richly vascularized/ loose supportive stroma
• Dissipates by term
• Poor control of cerebral blood flow

26
(No Transcript)
27
IVH

• Grade I
• Germinal matrix only (subependymal)
• Grade II
• Intraventricular/ normal ventricles
• Grade III
• IVH dilated ventricles
• Grade IV
• IVH parenchymal bleed

• Screening head u/s
• lt 34 weeks
• Management
• Supportive, ventricular taps, reservoirs, VP
  shunts
• Prognosis

28
Day 14

• 2 spits yesterday of small amount of formula
• 10cc bilious residual this am on premature
  formula (16cc q3hr)

29
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

30
NEC- Signs and Symptoms

• Abdominal
• distension, tenderness, discoloration, mass
• Feeding intolerance
• Vomiting (bilious), gastric residuals, heme ()/
  bloody stools
• Systemic
• Lethargy, apnea, poor perfusion, temp instability

• Labs
• reflect sepsis
• leukocytosis/ leukopenia,
• L shift
• thrombocytopenia
• acidosis
• hypo/hyperglycemia
• hypoxia/hypercapnea

31
NEC- radiograph

• Pneumatosis intestinalis
• thickened bowel wall
• sentinel loop
• soap bubble appearance (RLQ)

32
NEC

• Pneumoperitoneum
• Portal venous air

33
NEC- Pathophysiology

• Onset?
• 3-10 days (24hr-3mo)
• Where?
• Jejunum, ileum, colon
• What?
• Bowel necrosis, edema, hemorrhage, perforation

• Etiology?
• Multifactorial
• GI dysmotility/ stasis
• Partially digested formula substrate for
  bacterial proliferation
• Mucosal injury/ bacterial invasion
• Mesenteric ischemia
• Inflammatory mediators

34
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 necrotic bowel with ostomy
• Peritoneal drain

35
Day 38

• 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

36
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

37
Chronic lung disease (CLD or BPD)

• Treatment with oxygen gt21 for at least 28 days
  plus
• Mild BPD Breathing room air at 36 weeks
  postmenstrual age (PMA) or discharge
• Moderate BPD Need for lt30 oxygen at 36 weeks
  PMA or discharge
• Severe BPD Need for 30 oxygen and/or positive
  pressure (ventilation or continuous positive
  airway pressure) at 36 weeks PMA

38
BPD- Pathophysiology
39
Day 38

• What should have been ordered by now??

40
Diagnosis

• BPD
• IVH
• PDA
• ROP

• ROS
• SDS
• AOP
• NEC

41
Retinopathy of prematurity (ROP)

• Risk factors?
• Prematurity, oxygen exposure
• Vasoconstriction? vaso-obliteration?
  neovascularization
• Classification
• Stages 1-5
• Zones I-III

42
ROP- Stages Zones

• 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 zone- worse disease state

43
ROP screening

• lt 1500gm or 32 weeks
• Selected infants gt1500gm, gt 32 weeks
• AAP policy statement
• Pediatrics 117(2), 2/06

44
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
Who is the most famous person affected by ROP?
46
(No Transcript)