The Very Low Birth Weight Infant

Dana Rivera, M.D.

Delivery

A 800 gram female infant at 26 weeks

Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption

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

ETT size selection

Position?

< 1kg: 2.5 1-2 kg: 3.0 2-3 kg: 3.5 > 3 kg: 4

between clavicles and carina

Umbilical lines?

UVC

Intrathoracic IVC

Just above diaphragm

High:

UAC

T6-9, T7-10 below L3

Low:

Initial Hours

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Surfactant Deficiency Syndrome Signs and Symptoms

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

CxR: ground glass underinflation air bronchograms

Surfactant Deficiency Syndrome Physiology

Made by?

Type II pneumocytes ~23 weeks, inadequate until ~32 weeks 70-80% phospholipids Prevents high surface tension

Detected by?

Made of?

Works by?

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

Surfactant Deficiency Syndrome Management

Prevention Respiratory support Surfactant replacement

Side effects

Antibiotics Maintain Hct

Day # 2

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

Day #4

Increased ventilator support overnight

ABG: 7.22/50/50/16/-7
Murmur

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Patent Ductus Arteriosus Signs and Symptoms

Murmur Widened pulse pressure Hyperactive precordium Bounding pulses Metabolic acidosis

PDA- Pathophysiology

LR shunt

Pulmonary congestion L-sided overload CHF

Diagnosis

ECHO

PDA- Management

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

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?

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Apnea of Prematurity

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

Caffeine

Caffeine

Stimulates medullary respiratory center Increased sensitivity to CO2 Enhanced diaphragmatic contractility Diuretic

Enhanced catecholamine response

Increased cardiac output/ HR

Increased glucose (glycogenolysis) GER

Day #7

What is the one test you should order today??

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Intraventricular Hemorrhage Signs and Symptoms

Catastrophic

Saltatory

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

Cycle of deterioration and recovery

Silent: 50%

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

IVH

Grade I

Germinal matrix only (subependymal)

Grade II

Intraventricular/ normal ventricles IVH + dilated ventricles IVH + parenchymal bleed

Grade III

Grade IV

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

Day #14

2 spits yesterday of small amount of formula

10cc bilious residual this am on premature formula (16cc q3hr)

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

NEC- Signs and Symptoms

Abdominal

Labs

distension, tenderness, discoloration, mass Vomiting (bilious), gastric residuals, heme (+)/ bloody stools Lethargy, apnea, poor perfusion, temp instability

Feeding intolerance

Systemic

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

NEC- radiograph

Pneumatosis intestinalis

thickened bowel wall

sentinel loop soap bubble appearance (RLQ)

NEC

Pneumoperitoneum

Portal venous air

NEC- Pathophysiology

Onset?

Etiology?

3-10 days (24hr3mo) Jejunum, ileum, colon

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

Where?

What?

Bowel necrosis, edema, hemorrhage, perforation

NEC- Management

Medical

Surgical

Bowel rest Decompression Broad spectrum Abx Serial radiographs Fluid/ nutritional support Blood product support BP support Respiratory/metabolic support

Pneumoperitoneum, fixed abdominal mass, persistently dilated loop, abdominal discoloration, persistent clinical deterioration Resection of necrotic bowel with ostomy Peritoneal drain

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

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Chronic lung disease (CLD or BPD)

Treatment with oxygen >21% for at least 28 days plus Mild BPD: Breathing room air at 36 weeks postmenstrual age (PMA) or discharge Moderate BPD: Need for <30% 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

BPD- Pathophysiology

Day #38

What should have been ordered by now??

Diagnosis

BPD

ROS

IVH
PDA ROP

SDS
AOP NEC

Retinopathy of prematurity (ROP)

Risk factors?

Prematurity, oxygen exposure

Vasoconstriction vaso-obliteration neovascularization Classification

Stages 1-5 Zones I-III

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 zoneworse disease state

ROP screening

< 1500gm or 32 weeks Selected infants >1500gm, > 32 weeks AAP policy statement

Pediatrics 117(2), 2/06

Gestational age

Postmenstrual

Chronologic

22 23 24 25 26 27 28 29 30 31 32

31 31 31 31 31 31 32 33 34 35 36

9 8 7 6 5 4 4 4 4 4 4

Who is the most famous person affected by ROP?