Extreme preterm Extreme preterm newborns – newborns –

survivorship and survivorship and ControversiesControversies

Dr. Varsha Atul ShahDr. Varsha Atul ShahConsultant, Neonatal and Developmental Medicine, Consultant, Neonatal and Developmental Medicine,

Singapore General HospitalSingapore General HospitalDept Child Development Medicine, K K HospitalDept Child Development Medicine, K K Hospital

Topic DiscussionTopic Discussion

IntroductionIntroduction DefinitionDefinition CausesCauses ManagementManagement ControversiesControversies Survival/outcomesSurvival/outcomes

Rumaisa, born sept 2004, in Rumaisa, born sept 2004, in illinoise, 240gm, 25+6/52,24cmillinoise, 240gm, 25+6/52,24cm

IntroductionIntroduction

30 years marked improvement in survival 30 years marked improvement in survival of extreme preterm infants (EPTI)of extreme preterm infants (EPTI)

US data: 70 fold rise in survivalUS data: 70 fold rise in survival Last 10 years, introduction of surfactant, Last 10 years, introduction of surfactant,

with no decrease in neurodevelopmental with no decrease in neurodevelopmental morbiditymorbidity

1980-2000: IMR from 12.6 to 6.9/1000 1980-2000: IMR from 12.6 to 6.9/1000 LB with 17% in preterm infantsLB with 17% in preterm infants

IncidenceIncidence

1% of live birth1% of live birth 50% mortality50% mortality

What is extreme prematurity?What is extreme prematurity?

Old definition: Infants born <28 completed Old definition: Infants born <28 completed weeks of pregnancy are called "extremely weeks of pregnancy are called "extremely premature." premature."

New definition: Infants born between New definition: Infants born between 22 22 to 2to 255 completed weeks of pregnancy completed weeks of pregnancy are called "extremely premature." are called "extremely premature."

Ref: Ref: Key Topics in NeonatologyKey Topics in NeonatologyBy Richard H. Mupanemunda, Michael By Richard H. Mupanemunda, Michael

Watkinson, David Harvey, ebrary Watkinson, David Harvey, ebrary

ManagementManagement

THE ACUTE STAGE THE ACUTE STAGE FIRST 72 HOURSFIRST 72 HOURS

THE STABLE STAGE THE STABLE STAGE FIRST 2 WEEKSFIRST 2 WEEKS

THE LATE STAGETHE LATE STAGE

THE ACUTE STAGE THE ACUTE STAGE INTRAVENTRICULAR HEMORRHAGEINTRAVENTRICULAR HEMORRHAGE RESPIRATORY DISTRESS SYNDROMERESPIRATORY DISTRESS SYNDROME BLOOD PRESSURE STABILIZATIONBLOOD PRESSURE STABILIZATION PATENT DUCTUS ARTERIOSUSPATENT DUCTUS ARTERIOSUS FLUID AND METABOLIC BALANCE FLUID AND METABOLIC BALANCE SKIN PROTECTIONSKIN PROTECTION

THE STABLE STAGETHE STABLE STAGE APNEA OF PREMATURITYAPNEA OF PREMATURITY MINIMAL ENTERAL FEEDINGMINIMAL ENTERAL FEEDING VESSEL ACCESS VESSEL ACCESS INFECTION CONTROLINFECTION CONTROL NECROTIZING ENTEROCOLITISNECROTIZING ENTEROCOLITIS

THE LATE STAGETHE LATE STAGE

BRONCHOPULMONARY DYSPLASIABRONCHOPULMONARY DYSPLASIA RETINOPHATY OF PREMATURITYRETINOPHATY OF PREMATURITY PERIVENTRICULAR LEUKOMALACIAPERIVENTRICULAR LEUKOMALACIA OSTEOPENIA OF PREMATURITYOSTEOPENIA OF PREMATURITY

THE ACUTE STAGE THE ACUTE STAGE MANAGEMENT DURING 72 HOURSMANAGEMENT DURING 72 HOURS

PREVENTIVE SURFACTANT PREVENTIVE SURFACTANT CONVENTIONAL MECHANICAL VENTILATIONCONVENTIONAL MECHANICAL VENTILATION HFV - INTERSTITIAL EMPHYSEMAHFV - INTERSTITIAL EMPHYSEMA MEAN BLOOD PRESSURE ABOVE 30torrMEAN BLOOD PRESSURE ABOVE 30torr INDOMETHACIN - IVH PROPHYLAXIS, PDAINDOMETHACIN - IVH PROPHYLAXIS, PDA SEDATIONSEDATION ANTIBIOTICS, NO TAPES ON SKINANTIBIOTICS, NO TAPES ON SKIN WATER TO AVOID HYPERNATREMIAWATER TO AVOID HYPERNATREMIA GLUCOSE , CALCIUM AND INSULIN IF NEEDED GLUCOSE , CALCIUM AND INSULIN IF NEEDED

(HYPERGLYCEMIA, HYPERKALEMIA)(HYPERGLYCEMIA, HYPERKALEMIA)

THE STABLE STAGETHE STABLE STAGE MANAGEMENT MANAGEMENT

FIRST HEAD US (DAY 3)FIRST HEAD US (DAY 3) EXTUBATION (DAY 3-5), NASAL CPAPEXTUBATION (DAY 3-5), NASAL CPAP AMINOPHYLLINE, DOXOPRAM TREATMENTAMINOPHYLLINE, DOXOPRAM TREATMENT PARENTERAL NUTRITION PARENTERAL NUTRITION THE UAC IS PLACED AT LOW POSITION OR THE UAC IS PLACED AT LOW POSITION OR

REPLACED WITH A PERIPHERAL A .LINEREPLACED WITH A PERIPHERAL A .LINE UVC IS REPLACED WITH A PCCV LINEUVC IS REPLACED WITH A PCCV LINE MINIMAL ENTERAL FEEDING (DAY 4 - 7)MINIMAL ENTERAL FEEDING (DAY 4 - 7) FULL FEEDING (DAY 14) FULL FEEDING (DAY 14)

THE LATE STAGETHE LATE STAGEMANAGEMENTMANAGEMENT

SECOND HEAD US ( 2- 3 WEEKS )SECOND HEAD US ( 2- 3 WEEKS ) FIRST EYE EXAMINATION AND THIRD FIRST EYE EXAMINATION AND THIRD

HEAD US ( 4 -6 WEEKS )HEAD US ( 4 -6 WEEKS )