Date post: | 14-Jan-2016 |
Category: |
Documents |
Upload: | avice-atkinson |
View: | 224 times |
Download: | 1 times |
Prematurity: ComplicationsPrematurity: Complications Respiratory distress syndromeRespiratory distress syndrome Bronchopulmonary dysplasiaBronchopulmonary dysplasia Apnea of prematurityApnea of prematurity Patent ductus arteriosusPatent ductus arteriosus Intraventricular hemorrhageIntraventricular hemorrhage Periventricular leukomalaciaPeriventricular leukomalacia Necrotizing enterocolitisNecrotizing enterocolitis SepsisSepsis AnemiaAnemia Retinopathy of prematurityRetinopathy of prematurity
Respiratory Distress Respiratory Distress SyndromeSyndrome
EtiologyEtiology Anatomic immaturity of the lungAnatomic immaturity of the lung
Increased interstitial and alveolar Increased interstitial and alveolar lung fluidlung fluid
Surfactant deficiencySurfactant deficiency
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
17Weeks
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
22Weeks
Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html
25Weeks
CXR: poor aeration, ground-glass CXR: poor aeration, ground-glass appearance, homogenous, air appearance, homogenous, air
bronchogramsbronchograms
Respiratory Distress Respiratory Distress SyndromeSyndrome
Management:Management: Prevention - antenatal steroidsPrevention - antenatal steroids
Positive pressure ventilationPositive pressure ventilation
OxygenOxygen
+/- Surfactant (requires intubation)+/- Surfactant (requires intubation)
Pressure (cmHPressure (cmH220)0)
Vol
um
e (m
l)V
olu
me
(ml)
Bronchopulmonary Bronchopulmonary DysplasiaDysplasia
Respiratory symptoms, x-ray Respiratory symptoms, x-ray abnormalities, and O2 req’t for > 28 d and abnormalities, and O2 req’t for > 28 d and persisting at 36 wks corrected GApersisting at 36 wks corrected GA
Pathophysiology: Disturbed alveolarization with increased
alveolar-to-capillary distance and decreased alveolar-to-capillary ration
Secondary to:• Lung inflammation• Mucociliary dysfunction• Airway narrowing• Hypertrophied airway smooth muscle• Alveolar collapse• Constriction of pulmonary vascular bed
Bronchopulmonary Bronchopulmonary DysplasiaDysplasia
Management:Management: Prevention: IM Vitamin A, CaffeinePrevention: IM Vitamin A, Caffeine NUTRITIONNUTRITION Oxygen +/- ventilationOxygen +/- ventilation +/- Diuretics+/- Diuretics +/- Steroids: systemic, inhaled+/- Steroids: systemic, inhaled +/- Bronchodilators+/- Bronchodilators
Prognosis:Prognosis: Increased respiratory illnesses in childhoodIncreased respiratory illnesses in childhood Decreased long-term lung functionDecreased long-term lung function BUT, fine in the playground by pre-school age (usually BUT, fine in the playground by pre-school age (usually
…)…)
Apnea of PrematurityApnea of Prematurity
Central, obstructive, or mixedCentral, obstructive, or mixed Majority of <32 weeksMajority of <32 weeks Treat with:Treat with:
Adequate positioningAdequate positioning OxygenOxygen Methylxanthines (i.e. Caffeine)Methylxanthines (i.e. Caffeine) CPAPCPAP Ventilation if necessaryVentilation if necessary
Patent ductus arteriosusPatent ductus arteriosus Seen in >60% of <1000 g babiesSeen in >60% of <1000 g babies Management strategies:Management strategies:
Preload/afterload reductionPreload/afterload reduction Adequate oxygenationAdequate oxygenation Optimize pHOptimize pH Indomethacin/IbuprofenIndomethacin/Ibuprofen Surgery (PDA ligation)Surgery (PDA ligation) Conservative managementConservative management
Prognosis:Prognosis: Multiple associations (NEC, CLD, etc …) but no Multiple associations (NEC, CLD, etc …) but no
proven causationproven causation
Metabolic Problems of Metabolic Problems of PrematurityPrematurity
HypoglycemiaHypoglycemia
Fluid/electrolyte imbalanceFluid/electrolyte imbalance
Hypocalcemia/hypomagnesemiaHypocalcemia/hypomagnesemia
HyperbilirubinemiaHyperbilirubinemia
HypothermiaHypothermia
Intraventricular hemorrhageIntraventricular hemorrhage Common in < 1500 gm babiesCommon in < 1500 gm babies Usually evident in 1st week of lifeUsually evident in 1st week of life
Reasons:Reasons: highly vascularized germinal matrixhighly vascularized germinal matrix less basement membrane to capillariesless basement membrane to capillaries abnormal cerebral autoregulationabnormal cerebral autoregulation
Prognosis:Prognosis: GoodGood - small amounts of bleeding in the - small amounts of bleeding in the
ventriclesventricles PoorerPoorer - large amount intraparenchymally or if - large amount intraparenchymally or if
post-hemorrhagic hydrocephaluspost-hemorrhagic hydrocephalus
Periventricular leukomalaciaPeriventricular leukomalacia
Pathophysiology:Pathophysiology: Ischemic lesion to watershed area Ischemic lesion to watershed area
around ventricles in premature infantsaround ventricles in premature infants Link to inflammation?Link to inflammation? Most often shows up 3-4 wks after Most often shows up 3-4 wks after
deliverydelivery
Prognosis:Prognosis: Correlated with cerebral palsyCorrelated with cerebral palsy
Necrotizing EnterocolitisNecrotizing Enterocolitis 1-5% NICU admissions1-5% NICU admissions Multi-factorial etiology:Multi-factorial etiology:
Feeds, Prematurity, Ischemia, InfectionFeeds, Prematurity, Ischemia, Infection Diagnosis:Diagnosis: clinical and radiologic clinical and radiologic Treatment:Treatment:
Decompression (NPO, NG tube)Decompression (NPO, NG tube) AntibioticsAntibiotics Surgery prnSurgery prn
Prognosis:Prognosis: 30% mortality if <1500 g30% mortality if <1500 g
SepsisSepsis Suboptimal immune function in preemies Suboptimal immune function in preemies
plus poor skin barrier, indwelling cathetersplus poor skin barrier, indwelling catheters
GBS and coliforms cause early onset sepsisGBS and coliforms cause early onset sepsis
< 5-7 days of life< 5-7 days of life
Nosocomial sepsis common in premsNosocomial sepsis common in prems Most common = coagulase negative Most common = coagulase negative
staphylococcusstaphylococcus Fungi can also be problematic in > 1 week of lifeFungi can also be problematic in > 1 week of life
Anemia of PrematurityAnemia of Prematurity
Reasons:Reasons: decreased hemoglobin at deliverydecreased hemoglobin at delivery decreased RBC survivaldecreased RBC survival blunted erythropoietin responseblunted erythropoietin response IATROGENICIATROGENIC
Treatment:Treatment: preventionprevention iron supplementationiron supplementation transfusiontransfusion EPOEPO
Retinopathy of PrematurityRetinopathy of Prematurity 40-70% NICU survivors < 1000 g40-70% NICU survivors < 1000 g
Etiology:Etiology: vasoconstriction leading to abnormal vasoconstriction leading to abnormal
vascular proliferationvascular proliferation
Diagnosis:Diagnosis: ScreeningScreening
Treatment:Treatment: Close monitoring, laser if necessaryClose monitoring, laser if necessary
Long Term Outcomes – 24 Long Term Outcomes – 24 weeksweeks
Local survival (2006-2008) ~ 60%
Risk of severe disability: very low IQ, unable to walk, blindness and/or deafness
~ 15-20% of survivors
Risk of moderate disability: low IQ, walk with aid, impaired vision and/or correctable hearing loss
~ 20-30% of survivors
Deafness ~ 2% of survivors
Blindness 1-10% of survivors
Overall, chance of being ‘normal’ or mildly impaired
~ 50-65% of survivors
Disorders of gestation Disorders of gestation length or of growthlength or of growth
Small for gestational age: <2SD Small for gestational age: <2SD belowbelow
Large for gestational age: >2SD Large for gestational age: >2SD aboveabove
Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation
Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation