Arvind Shenoi

Consultant neonatologist and Medical Director

Cloudnine Hospital Bangalore

MD (Pediatrics) DM Neonatology(PGIMER)

Neonatal sepsis, Vitamin D in neonatal nutrition

Clinical examination First!

Why a debate?

Dr. Arvind Shenoi

Consultant neonatologist & Medical Director

Cloudnine Hospital, Old Airport road, Bangalore

Case 1

• 34 week male neonate, shifted from labour room with mild tachypnea, gradually worsened,

by 2hours had grunting, tachypnea and retractions.

• Clinical exam

• Reduced air entry in rt hemi-thorax

Clinical exam saves lives!

Case2: BOH

• Full term neonate – G3 P2 L0 pregnancy – previous babies died at 1 week age, no details

available. This baby uneventful pregnancy 2.8kg 38 weeks elective LSCS, was well for 2

days, then developed lethargy, tachypnea and was referred ……

IEM

Such a baby should have been admitted at birth, supervised feed challenge

Full IEM/ Genetic workup

History gives

diagnosis

Case 3

• A full term neonate 3.4 kg was delivered by elective cesarean section was found grunting

at 45 min age.

• Clinical exam – found baby to be jittery

• On exam – registrar found baby feet and hands were cold

• Rectal temp 35C

• Cold stress !

• Warmer care followed by Skin to skin contact

Clinical exam

gives

diagnosis

Clinical > lab > gadgets

Clinical exam

Monitoring

Appropriate labs

Management decision

Reassess and Monitor

History & Clinical exam

labs

Gadgets

At admission

In NICU

Gadgets also need to be monitored!

Monitor

software

Electricity

Probes/ tubes/ wires

All these can

malfunction

Why gadgets fail

• Probe placement and displacement and failure

• Imperfect algorithms

– Interference by ambient light and motion- PULSE OXIMETER

– Interference from other equipment- EEG

– Alarm problems

• Electro-mechanical dysfunction- ventilators

• Electricity related malfunction

Where is the evidence?

• Shellenberger RA et al

• Cleve Clin J Med. 2017

Dec;84(12):943-950. doi:

10.3949/ccjm.84a.16127.

• Developed a clinical

algorithm to diagnose

pneumonia vs pleural

effusion in patients

presenting with dyspnea

• Benchmarked it against chest

x- ray and chest ultrasound

Asymmetrical chest expansion, diminished breath sounds,

egophony, bronchophony, and tactile fremitus can be used

in combination to accurately diagnose pneumonia and pleural effusion.

Clinical exam vs. MRI

• One study found that clinical diagnostic tests were superior to MRI when diagnosing an

ACL tear.JNU Aligarh

• One study found that, when conducted proficiently, clinical diagnostic tests were equal to

MRI when measuring sensitivity, but scored higher in specificity, positive predictive value

(PPV), negative predictive value (NPV), and diagnostic accuracy.5

• One author determined that when diagnosing ACL tears, clinical diagnostic tests scored

higher than MRI on specificity and PPV, were equal when measuring accuracy, and scored

lower when measuring sensitivity and NPV.4

Clinical Bottom Line

• The evidence supports the use of clinical diagnostic tests when diagnosing an ACL tear.

Clinical diagnostic tests are equally or more diagnostically accurate as an MRI in the

diagnosis of an ACL tear.

Brady MP, Weiss W. Clinical diagnostic tests vs MRI diagnosis fo ACL tears

J sport rehabilitation 2016: 27: 598-600

CPAP or Intubation (COIN) trial vs.

SUPPORT

• Nasal CPAP 8cm H2O vs. intubation

at 5min

• Babies on early CPAP

– Trend towards lower death rate or BPD

– Lesser use of corticosteroids

postnatally

– Mean duration of ventilation was

shorter (3vs.4)

– Higher rate of pneumothorax (9vs.3%)

– Only 50% required surfactant

N Engl J Med 2008;358:700-8.

CPAP group 5cm H2ODeath rate lower in 24-25 weeks gestation

(20% vs 29%)

Overall rate of death or BPD similar (48% vs

51%)

Only 67% received surfactant

Duration of mechanical ventilation was

shorter (25vs 28 days)

Lower rate of postnatal corticosteroids (7%

vs13%)

No difference in airleaks

Death or neurodevelopmental impairment

(28% vs 30%)

SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network,

Finer NN, Carlo WA, Walsh MC, Rich W, et al. (2010)

Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 362: 1970- 1979.

Limits of clinical exam- Lab

• Is clinical exam perfect – NO!!!

• It is defined by

– Seniority – presumably senior people have already committed most of the mistakes and learnt from

them!

– Tiredness & over work

– Time of the day/ Night – most mistakes occur just before shift change !

– Human factors – communication, mood, mis-interpretation, lack of team work

• It has limitations in

– Metabolic diagnosis – acidosis, dyselectrolytemia, hyperammonemia, IEM, renal failure,

– Micro-biological diagnosis - ??Sepsis

– Xray and ultrasound/ Echo definitely add to clinical exam

– Trends are difficult to pick up

Laboratory thus

extends the

clinicians reach

Limits of gadgets

• In addition to the limitations mentioned above

• Interpretation & quality of images are dependant on

the experience and skill of operator- eg. ECHO,

ultrasound

• Interpretation of physiological data – dependant on

software and its limitations

• Gadgets add to the cost of medical care

Hierarchy

Clinical exam

lab

Gadget

radiology

nursing

The future

• Gadgets which can do clinical exam

• Gadgets which interpret data and trends - AI

• Gadgets which can do procedures

Thank You

BENGALURU CHENNAI MUMBAIPUNEGURUGRAM CHANDIGARH

.

Website

http://cloudninecare.com/