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Published byJudith Cunningham Modified over 9 years ago
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S.F. Delivered via NSD 32 y/o G2P1 (1011) 39 5/7 weeks AOG, MT 39 AGA
AS 8,9 BW 3265g BL 49cm HC 36cm CC 33cm AC 30cm
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Maternal History: PROM 18 hours prior to delivery Ob History: G1 – 2008, abortion at 7 weeks s/p D&C G2 – present pregnancy
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Pertinent PE Caput Good cry and activity Clear amniotic fluid
Flat and open fontanelles Good air entry, no retractions Grade 1-2 systolic murmur Soft abdomen Grossly male genitalia, with urine output at delivery room Full pulses
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Diagnosis Term baby Boy Sepsis, unspecified
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Problem 1: Respiratory Distress
2nd hour of life Cyanosis HR 150 RR 50s T 36.9C O2 sat 70% at room air BP: 60-66mmHg/ mmHg all extremities Good cry and activity Adynamic precordium gr 2/6 systolic murmur at left parasternal border Full pulses Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified Refer to Neonatologist Refer to Pediatric cardiologist IV at TFR 80 Hyperoxia test BCS, CBC, CRP, Hgt Start Ampicililn, Amikacin Chest xray to rule out Pneumonia Hook to O2 at 1 LPM Transfer to level 3
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Problem 1: Respiratory Distress
ABG 6LPM pH 7.287 pCO2 31.4 pO2 92.8 HCO3 15 O2 96% BE -10.3 Metabolic acidosis Hgt = 115 mg/dL Bcs: No growth after 7 days CRP = 0.02 mg/dL Hgb Hct WBC Bands Neu Lym Mon Eos Plt 184 55 21.1 2 70 21 6 1 190
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CXR CXR: bilateral lung opacities suggestive of TTNB. Underlying Pneumonia is not ruled out
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Problem 1: Respiratory Distress
9th hour of life Good cry and activity Desaturations as low at 70% at 2-3LPM RR 62 T 37C (+) suprasternal and subcostal retractions Persistent Pulmonary Hypertension vs Cyanotic Heart disease Sepsis, unspecified Increase O2 support to 2LPM For 2d Echo Give midazolam for sedation 2D-echo Elevated estimated right ventricular and pulmonary pressures; flattened interventricular septum and TR jet of 61 mmHg (systolic BP of 71 mmHg) + right atrial pressure Large bidirectional PDA Moderate right ventricular dilation Mild ventricular hypertrophy Good biventricular systolic function Increasing 02 requirement 2d echo results: elevated estimated right ventricular and pulmonary pressures: flattened interventricular septum and TR jet of 61 mmHg (systolic BP of 71mmHg) + right atrial pressure Moderate right ventricular dilatation Mild ventricular hypertrophy Good biventricular systolic function Large bidirectional PDA No pericardial effusion
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Problem 1: Respiratory Distress
12th hour of life Good cry and activity (+) Difficulty breathing (+) grunting Desaturations as low at 70% at 4lpm via RR cpm (+) Alar flaring (+) chest indrawing (+) suprasternal, and subcostal retractions Persistent Pulmonary Hypertension Pneumonia Patent Ductus Arteriosus Sepsis, unspecified Endotracheal Intubation Mech vent settings: FiO2 100 PIP 20 PEEP 6 IT 0.4 RR 70 Insert UVC Shift antibiotics to Cefotaxime
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ABG 6LPM 2/18 1 hr post intubation pH 7.287 7.346 pCO2 31.4 44.6 pO2 92.8 97.9 HCO3 15 24.4 O2 96% 96.9 BE -10.3 -1.2 Metabolic acidosis Respiratory acidosis 2d Echo: Elevated estimated right ventricular and pulmonary pressures; flattened interventricular septum and TR het of 61 mmHg (systolic BP of 71 mmHg) + right atrial pressure Moderate right ventricular dilation Mild ventricular hypertrophy Good biventricular systolic function Large bidirectional PDA No pericardial effusion
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CXR Bilateral opacities with interval regression
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ABG 6LPM 2/18 1 hr post intubation 2/19 FiO PEEP 5, PIP 20 RR 60 pH 7.287 7.346 7.397 pCO2 31.4 44.6 54.3 pO2 92.8 97.9 46.6 HCO3 15 24.4 33.3 O2 96% 96.9 81.8 BE -10.3 -1.2 7.7 2/19 Crea 0.57 iCal 0.98 Na 135 K 3.7
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Problem 1: Respiratory Distress
2nd day of life Intubated NPO No desaturations No cyanosis T RR 71 BP 66/45 Jaundice Equal chest rise, Good air entry, harsh breath sounds Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; Pneumonia PDA; Sepsis, unspecified Reinsert OGT Start breastmilk feeding 3ml every 3 hours Start phototherapy Slowly weaned from MV, extubated on 6th DOL and shifted to CPAP for 3 days
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Problem 2: Jaundice S O A P 2nd day of life Intubated
Tolerates 3ml of milk via OGT No desaturations No cyanosis HR RR 60-74 BP 61-72/29-45 O2 sat % Jaundice to abdomen Good air entry Good cardiac tone Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Hyperbilirubinemia, unspecified; Sepsis, unspecified Phototherapy started Mech vent settings: FiO2 70 RR 60 PIP 16 PEEP 4 Increase feedings to 5ml every 3 hours
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Problem 2: Jaundice S O A P 3nd day of life Intubated
Tolerates 5ml of milk via OGT No desaturations No cyanosis HR RR 60-74 BP 61-72/29-45 O2 sat % Jaundice to chest Good air entry Good cardiac tone Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Hyperbilirubinemia, unspecified; Sepsis, unspecified Phototherapy started, continued for 2 days Mech vent settings: FiO2 70 RR 60 PIP 16 PEEP 4 Increase feedings to 5ml every 3 hours
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Problem 2: Jaundice S O A P 4th day of life Intubated
Tolerates 5ml of milk via OGT No desaturations No cyanosis RR 58-73 O2 sat % No alar flaring Jaundice to upper chest Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA; Hyperbilirubinemia, unspecified; Sepsis,unspecified Phototherapy Mech vent settings: FiO2 50 RR 40 PIP 16 PEEP 4 SIMV For VBG, Na, K, Ical, DBIB Total Bilirubin 14.49 LIRZ Direct Bilirubin 0.73 Indirect Bilirubin 14.08
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ABG 6LPM 2/18 1 hr post intubation 2/19 FiO PEEP 5, PIP 20 RR 60 2/21 FiO2 40 PEEP 4 PIP 16 RR 30 pH 7.287 7.346 7.397 7.352 pCO2 31.4 44.6 54.3 56.8 pO2 92.8 97.9 46.6 42.8 HCO3 15 24.4 33.3 31.5 O2 96% 96.9 81.8 74.8 BE -10.3 -1.2 7.7 5.1 2/19 2/21 Crea 0.57 iCal 0.98 1.33 Na 135 K 3.7 4.4 Total Bilirubin 14.49 LIRZ Direct Bilirubin 0.73 Indirect Bilirubin 14.08
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Course in the Wards S O A P 5th day of life Intubated
Tolerates 10ml of milk via OGT No desaturations No cyanosis RR 51-62 HR O2 sat 92-96% Jaundice to face No alar flaring Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia, unspecified Mech vent settings: FiO2 35 RR 25 PIP 15 PEEP 4 SIMV Increase feedings to 15ml every 3 hours Transfer to isolette
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Course in the Wards S O A P 6th day of life Intubated
Tolerates 15ml of milk via OGT No desaturations No cyanosis RR 58-71 HR O2 sat 92-96% Light Jaundice to face No alar flaring Shallow subcostal retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia For extubation Hook to CPAP
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Course in the Wards S O A P 7th-11th day of life CPAP
Tolerates 30ml of milk via OGT No desaturations No cyanosis RR 48-64 HR O2 sat % Light Jaundice to chest No alar flaring No retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified Hyperbilirubinemia Continue feedings Possible weaning off CPAP
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Course in the Wards S O A P 12-15th day of life
Tolerates 30ml of milk via OGT No desaturations No cyanosis RR 48-55 HR O2 sat % No alar flaring No retractions Good air entry Regular cardiac rhythm Soft abdomen Full pulses Persistent Pulmonary Hypertension; PDA Pneumonia Sepsis,unspecified, resolved Hyperbilirubinemia, resolved Continue feedings Discharged on the 15th day of life.
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Update 16th day of life Discharged on the 14th day of life stable
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Persistent pulmonary Hypertension
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Definition Persistent Fetal Circulation (PFC)
Pulmonary hypertension resulting in severe hypoxemia secondary to right-to-left shunting through the foramen ovale and ductus arteriosus in the absence of structural heart disease Pulmonary
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Typically seen in: Full term or post term infants
37-41 weeks gestational age within the first hours after birth.
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In Utero Fetal gas exchange occurs through the placenta instead of the lungs. PVR > SVR causes blood from the right side of the heart to bypass the lungs through the ductus arteriosus and foramen ovale.
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Fetal Shunts Ductus arteriosus Foramen ovale
R-L shunting of blood from pulmonary artery to the aorta bypasses the lungs. Usually begins to close hours after birth. Foramen ovale Opening between left and right atria. Closes when there is an increased volume of blood in the left atrium.
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At Birth First breath Decrease in PVR Increase in pulmonary blood flow and PaO2 Circulatory pressures change with the clamping of the cord. SVR >PVR allowing lungs to take over gas exchange. If PVR remains higher blood continues to be shunted and PPHN develops.
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Signs of PPHN Infants with PPHN are born with Apgar scores of 5 or less at 1 and 5 minutes. Cyanosis may be present at birth or progressively worsen within the first hours.
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Later developments Within a few hours after birth CXR tachypnea
retractions systolic murmur mixed acidosis, hypoxemia, hypercapnia CXR mild to moderate cardiomegaly decreased pulmonary vasculature
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Pulmonary Vasculature
Pulmonary vascular bed of newborn is extremely sensitive to changes in O2 and CO2. Pulmonary arteries appear thick walled and fail to relax normally when exposed to vasodilators. Capillaries begin to build protective muscle. (remodeling)
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Diagnosis Hyperoxia Test Place infant on 100% oxyhood for 10 minutes.
PaO2 > 100 mmHg parenchymal lung disease PaO2= mmHg parenchymal lung disease or cardiovascular disease PaO2 < 50 mmHg fixed R-L shunt cyanotic congenital heart disease or PPHN
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Hyperoxia Test (cont.) If fixed R-L shunt
need to get a preductal and postductal arterial blood gases with infant on 100% O2. Preductal- R radial or temporal artery Postductal- umbilical artery If > 15 mmHg difference in PaO2 then ductal shunting If < 15 mmHg difference in PaO2 then no ductal shunting
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Treatment Goals: To maintain adequate oxygenation.
These babies are extremely sensitive Handling them can cause a decrease in PaO2 and hypoxia Crying also causes a decrease in PaO2 Try to coordinate care as much as possible To maintain neutral thermal environment to minimize oxygen consumption.
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Mechanical Ventilation
TCPLV (Time cycled pressure limited ventilation) may be used with PPHN. Want to use low peak inspiratory pressures Monitor PaO2 and PaCO2 with a transcutaneous monitor
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Hyperventilation Hyperventilation helps promote pulmonary vasodilation
Respiratory Alkalosis- decrease PAP to level below systemic pressures to improve oxygenation by helping to close the shunts Try to keep pH =7.5 and PaCO2 = 25-30 Alkalizing agents - sodium bicarbonate or THAM
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Hyperventilation (cont.)
Babies often become agitated when they are hyperventilated May need to administer muscle relaxants and sedation usually given pancuronium and morphine pancuronium- q 1-3 hours IV at mg/kg morphine- continuous infusion 10 micrograms/kg/hr
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Nitric Oxide (NO) Potent pulmonary vasodilator
decrease pulmonary artery pressure increase PaO2 Does not cause systemic hypotension NO more effective in PPHN babies without lung disease Baby must be weaned slowly off NO or may have rebound hypertension
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Effects of NO NO is metabolized to nitrogen dioxide (NO2) which can cause acute lung injury. NO2 is potentially toxic. NO reacts with hemoglobin to form methemoglobin.
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Outcome PPHN may last anywhere from a few days to several weeks.
Mortality rate is 20-50%. Decreased by HFOV and NO Decreased by ECMO Babies treated with hyperventilation may develop sensorineural hearing loss.
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Thank you!
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