Critical NeonateCritical Neonate

Rafat Mosalli MDRafat Mosalli MD

Objectives

Describe the algorithm for neonatal Describe the algorithm for neonatal resuscitation and Delivery room resuscitation and Delivery room managementmanagement

Approach to a infant with Respiratory Approach to a infant with Respiratory distressdistress

Describe the etiology and effect of birth Describe the etiology and effect of birth asphyxiaasphyxia

Describe common birth injuriesDescribe common birth injuries

Case 1 ScenarioCase 1 Scenario

You are called to attend the delivery of a You are called to attend the delivery of a baby who is not born yet.baby who is not born yet.

What should you do firstWhat should you do first

Delivery Room Care: ResuscitationDelivery Room Care: Resuscitation

Detailed maternal hx, GADetailed maternal hx, GA

Preparation ( equipments and personals)Preparation ( equipments and personals)

Case 1

Baby is 35 weeks delivered now, breathing Baby is 35 weeks delivered now, breathing fast ,irregular, Nasal flaring,blue in color fast ,irregular, Nasal flaring,blue in color and intercostal Retractions?and intercostal Retractions?

how you would approach this newborn?how you would approach this newborn? What is your DD?What is your DD?

Case 1:ABCD first

APGAR SCOREAPGAR SCORE Resuscitation (NRP)Resuscitation (NRP) ABCDABCD Postnatal resuscitation.Postnatal resuscitation.

(Or 21%-100%)

Resuscitation Drugs

30 ml30 ml

20 ml20 ml

10 ml10 ml

Volume Expanders normal salinePacked red cells

6 ml4 ml2 mlGlucose D10WIV bolus200 mg/kgfor documentedhypoglycemia

0.75 ml0.5 ml0.25 mlNaloxone IV or IM0.4 mg/ml (0.1 mg/kg)

contraindicated in narcotic dependentmothers

12 ml8 ml4 mlSodium Bicarbonate IV4.2% (2 mmol/kg)0.5 mmol/ml for prolonged arrest

3 ml2 ml1 mlETT Route

(0.1 mg/kg)

0.3 ml0.2 ml0.1 mlIV Route

(Preferred route)

(0.01 mg/kg)

Epinephrine1:10,000 0.1 mg/mlq3-5 minutes

3 kg> 36 weeks

2 kg30-36 weeks

1 kg< 30 weeks

Differential Diagnosis

RDSRDS TTNTTN InfectionInfection MAMA

Respiratory Distress Syndrome (RDS)

Surfactant Production?Surfactant Production? ComplicationsComplications

Risk Factors

Premature babiesPremature babies Previous baby with RDSPrevious baby with RDS Maternal diabetesMaternal diabetes HypothermiaHypothermia Fetal Distress AsphyxiaFetal Distress Asphyxia Male sexMale sex Caucasian raceCaucasian race Second twinSecond twin C/S with out laborC/S with out labor

Signs of Respiratory Distress

Grunting Grunting Tachypnea (RR >60/m)Tachypnea (RR >60/m) Nasal flaring, chest indrawingNasal flaring, chest indrawing

Apnea

Obstructive Apnea:No air flow but the Obstructive Apnea:No air flow but the chest wall movements continuechest wall movements continue

Central Apnea:Central Apnea:

Complete cessation of airflow and Complete cessation of airflow and respiratory airflow and respiratory efforts respiratory airflow and respiratory efforts with no chest wall movementwith no chest wall movement

Mixed Apnea (Is the most frequent type)Mixed Apnea (Is the most frequent type)

CyanosisCyanosis

Deoxygenated hemoglobin is 5 g/dlDeoxygenated hemoglobin is 5 g/dl Types?Types? ACROCYANOSIS: blue color of the hands ACROCYANOSIS: blue color of the hands

and feet with pink color of the rest of the and feet with pink color of the rest of the body, common in delivery room and is body, common in delivery room and is usually NORMALusually NORMAL

Other Routine Delivery Room CareRoutine Delivery Room Care

Erythromycin eye drops?Erythromycin eye drops? Vitamin K IM?Vitamin K IM?

Case 2

You are called to attend a delivery for You are called to attend a delivery for baby with Meconuim liquor?baby with Meconuim liquor?

What you do first?What you do first?

Meconium/Suction

Meconium in Amniotic Fluid

Infant Active Infant Depressed

Absent or decreased respirations, decreased muscle tone

OR HR <100 bpm

Observe No stimulation

intubate and Suction Trachea

Resuscitate PRN

Depressed Meconium baby

MAS

MAS

Radiological appearance:Radiological appearance:

1-overexpanded lungs.1-overexpanded lungs.

2-coarse air space infiltrates.2-coarse air space infiltrates.

3-Wide spread consolidation.3-Wide spread consolidation.

4-+/-airleakage.4-+/-airleakage.

MAS and HIE !

The baby is born now and he is flat with The baby is born now and he is flat with Apgar score of ZERO?Apgar score of ZERO?

How do you proceed?How do you proceed?

Meconium Aspiration Syndrome

Complications:Complications: Severe Resp. failureSevere Resp. failure HIEHIE PPHN(persistent pulmonary hypertension)PPHN(persistent pulmonary hypertension) Pulmonary air leak Pulmonary air leak

Effect Of Asphyxia(HIE)Effect Of Asphyxia(HIE)

CNSCNS CVSCVS PulmonaryPulmonary RenalRenal AdrenalAdrenal GITGIT MetabolicMetabolic HematologyHematology

Treatment

ResuscitationResuscitation Post resuscitation:Post resuscitation:

Depend on severity(stage3 is the worst)Depend on severity(stage3 is the worst) Fluids restrictionsFluids restrictions O2 and ventilationO2 and ventilation InotropsInotrops Anti seizure medicationAnti seizure medication

Primary Pulmonary Hypertension of the Newborn (PPHN)

Severe hypoxemia, with out evidence of Severe hypoxemia, with out evidence of parenchymal lung or structural heart parenchymal lung or structural heart disease that also may cause right to left disease that also may cause right to left shunting.shunting.

Often seen in term or post-term infants Often seen in term or post-term infants who are asphyxiated or meconium stained who are asphyxiated or meconium stained fluidfluid

Case2

You are called to assess the same baby You are called to assess the same baby with MAS because of worsning respiartory with MAS because of worsning respiartory status and sudden status and sudden desaturation ,bradycardia and desaturation ,bradycardia and hypotension?hypotension?

What is your approach?What is your approach?

Treatment

Other Pulmonary Air Leaks

Pulmonary Interstitial Emphysema (PIE)Pulmonary Interstitial Emphysema (PIE) PneumomediastinumPneumomediastinum Subcutaneous EmphysemaSubcutaneous Emphysema PneumopericardiumPneumopericardium

Pneumonia

Pneumonia

Early Vs Late.Early Vs Late. Diagnosis is impossible from XR alone.Diagnosis is impossible from XR alone. frank lobar consolidation as seen in adults frank lobar consolidation as seen in adults

and older children is rare and older children is rare More commonly, there is coarse opacity of More commonly, there is coarse opacity of

one or more regions of the lung one or more regions of the lung parenchyma parenchyma

Transient Tachypnoea of the Newborn

Typically, respiratory symptoms resolve Typically, respiratory symptoms resolve within the first 24-hours of life, but within the first 24-hours of life, but occasionally can persist longer. occasionally can persist longer.

Typical radiologic features:Typical radiologic features: Increased central vascular markings Increased central vascular markings

Hyperaeration Hyperaeration Evidence of interstitial and pleural fluid Evidence of interstitial and pleural fluid Prominent interlobar fissures Prominent interlobar fissures

We Talked about!

Algorithm for neonatal resuscitation and Algorithm for neonatal resuscitation and Delivery room managementDelivery room management

Approach & DD of an infant with Approach & DD of an infant with Respiratory distressRespiratory distress

Effect of MAS and birth asphyxiaEffect of MAS and birth asphyxia