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...
TRANSCRIPT
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
Maternal History:- PROM 18 hours prior to delivery
Ob History:- G1 – 2008, abortion at 7 weeks s/p D&C- G2 – present pregnancy
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
Diagnosis
• Term baby Boy• Sepsis, unspecified
Problem 1: Respiratory DistressS O A P
2nd hour of lifeCyanosis HR 150 RR 50s T 36.9C
O2 sat 70% at room airBP: 60-66mmHg/ 45-51 mmHg all extremitiesGood cry and activityAdynamic precordium gr 2/6 systolic murmur at left parasternal borderFull 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
ABG 6LPM
pH 7.287
pCO2 31.4
pO2 92.8
HCO3 15
O2 96%
BE -10.3
Metabolic acidosis
Hgb Hct WBC Bands Neu Lym Mon Eos Plt
184 55 21.1 2 70 21 6 1 190
CRP = 0.02 mg/dL
Hgt = 115 mg/dL
Bcs: No growth after 7 days
Problem 1: Respiratory Distress
CXR
S O A P
9th hour of lifeGood cry and activity
Desaturations as low at 70% at 2-3LPMRR 62 T 37C(+) suprasternal and subcostal retractions
Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, 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 pressureLarge bidirectional PDAModerate right ventricular dilationMild ventricular hypertrophyGood biventricular systolic function
Problem 1: Respiratory Distress
S O A P
12th hour of lifeGood cry and activity(+) Difficulty breathing(+) grunting
Desaturations as low at 70% at 4lpm via RR 60-70 cpm (+) Alar flaring(+) chest indrawing(+) suprasternal, and subcostal retractions
Persistent Pulmonary HypertensionPneumonia
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
Problem 1: Respiratory Distress
ABG 6LPM 2/181 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 pressureModerate right ventricular dilationMild ventricular hypertrophyGood biventricular systolic functionLarge bidirectional PDANo pericardial effusion
CXR
S O A P
2nd day of lifeIntubatedNPONo desaturationsNo cyanosis
T 37.1 RR 71 BP 66/45JaundiceEqual chest rise, Good air entry, harsh breath soundsRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension; PneumoniaPDA;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
Problem 1: Respiratory Distress
S O A P
2nd day of lifeIntubatedTolerates 3ml of milk via OGTNo desaturationsNo cyanosis
HR 118-145RR 60-74BP 61-72/29-45O2 sat 96-100%Jaundice to abdomenGood air entryGood cardiac toneSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAHyperbilirubinemia, unspecified;Sepsis, unspecified
- Phototherapy started
- Mech vent settings:- FiO2 70- RR 60- PIP 16- PEEP 4- Increase feedings
to 5ml every 3 hours
Problem 2: Jaundice
S O A P
3nd day of lifeIntubatedTolerates 5ml of milk via OGTNo desaturationsNo cyanosis
HR 118-145RR 60-74BP 61-72/29-45O2 sat 96-100%Jaundice to chestGood air entryGood cardiac toneSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAHyperbilirubinemia, 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
Problem 2: Jaundice
Problem 2: JaundiceS O A P
4th day of lifeIntubatedTolerates 5ml of milk via OGTNo desaturationsNo cyanosis
RR 58-73O2 sat 94-100%No alar flaringJaundice to upper chestShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull 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
Course in the WardsS O A P
5th day of lifeIntubatedTolerates 10ml of milk via OGTNo desaturationsNo cyanosis
RR 51-62HR 125-151O2 sat 92-96%Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia, unspecified
- Mech vent settings:
- FiO2 35- RR 25- PIP 15- PEEP 4- SIMV- Increase
feedings to 15ml every 3 hours
- Transfer to isolette
Course in the WardsS O A P
6th day of lifeIntubatedTolerates 15ml of milk via OGTNo desaturationsNo cyanosis
RR 58-71HR 108-145O2 sat 92-96%Light Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia
- For extubation- Hook to CPAP
Course in the WardsS O A P
7th-11th day of lifeCPAPTolerates 30ml of milk via OGTNo desaturationsNo cyanosis
RR 48-64HR 110-152O2 sat 95-100%Light Jaundice to chestNo alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia
- Continue feedings
- Possible weaning off CPAP
Course in the WardsS O A P
12-15th day of lifeTolerates 30ml of milk via OGTNo desaturationsNo cyanosis
RR 48-55HR 110-152O2 sat 95-100%No alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses
Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecified, resolvedHyperbilirubinemia, resolved
- Continue feedings
Update
• 16th day of life• Discharged on the 14th day of life stable
PERSISTENT PULMONARY HYPERTENSION
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
Typically seen in:
• Full term or post term infants
• 37-41 weeks gestational age
• within the first 12-24 hours after birth.
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.
Fetal Shunts
• Ductus arteriosus– R-L shunting of blood from pulmonary artery to
the aorta bypasses the lungs.– Usually begins to close 24-36 hours after birth.
• Foramen ovale– Opening between left and right atria.– Closes when there is an increased volume of blood
in the left atrium.
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.
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 12-24 hours.
Later developments
• Within a few hours after birth– tachypnea– retractions– systolic murmur– mixed acidosis, hypoxemia, hypercapnia
• CXR– mild to moderate cardiomegaly– decreased pulmonary vasculature
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)
Diagnosis
• Hyperoxia Test• Place infant on 100% oxyhood for 10 minutes.– PaO2 > 100 mmHg parenchymal lung disease– PaO2= 50-100 mmHg parenchymal lung disease
or cardiovascular disease– PaO2 < 50 mmHg fixed R-L shunt cyanotic
congenital heart disease or PPHN
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
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.
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
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
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 0.1-0.2 mg/kg• morphine- continuous infusion 10 micrograms/kg/hr
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
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.
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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