NEONATAL PHYSIOLOGY -...
Transcript of NEONATAL PHYSIOLOGY -...
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NEONATAL PHYSIOLOGYJON PALMER, VMD, DACVIMNEW BOLTON CENTER, KENNETT SQUARE, PENNSYLVANIA
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Neonatal Period
Physiologic transition period Full dependence on maternal physiology
Adaptation to independent life
Period transition all organ systems
First 3 to 4 weeks of life
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Fetus Pediatric
Physiologic Transitions
Fetus Neonate PediatricFetus Neonate
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Counterintuitive Physiology
Different from Adult Physiology
Fetal Physiology
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Renal Response to Hypovolemia
Adult kidney Producing concentrated urine Maintain vascular volume
FetusConcentrated urine
Increase fetal fluid osmolarityPrevent reabsorption of the fluidsDraw fluid from the fetus Negative effect on volemia
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Renal Response to Hypovolemia
Produces dilute urine
Decrease fetal fluid osmolarity
Enhance reabsorption of fetal fluids
Positive effect on volemia
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Heart Rate Response To Hypoxemia
Adult Tachypnea and tachycardia Deliver more oxygen to tissues
Fetus Bradycardia Maximizing perfusion of fetal placenta Increasing vascular tone - directing blood to vital organs Increase in afterload
Increase cardiac work and thus oxygen demand Decrease HR
New circulatory pattern Requires no more oxygen
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Species
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Fluid Physiology
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Fluid PhysiologyFetus/Neonate
Unique characteristics of Fetal/ Neonatal Interstitium
Lymph flow
Capillary endothelial permeability
Interstitium Heterogeneous space
Dynamically controls its fluid content
Compliance 10X adult (fetal lamb)
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Fluid PhysiologyFetus/Neonate
Lymph flow Volume of lymph 1 mL/kg in adult dogs Thoracic duct lymph flow
Fetal lamb - 0.25 mL/minute/kg 5x the adult rate
Lymph flow - subcutaneous Puppies 2X adult dogs (per kg)
Pulmonary lymph flow Newborn lambs and puppies > adults
Neonate – local/ whole body lymph flow > adult Increased interstitial volume Higher capillary permeability
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Fluid PhysiologyFetus/Neonate
Capillary endothelial permeability Filtration rate in fetal lambs vs adults
Fluid 5x
Proteins 15x
Why? Poor precapillary tone
Higher capillary hydrostatic pressure
Higher filtration
The role of the glycocalyx?
Filtration related to hydrostatic pressure Precapillary tone lambs – develops during 1st week
Doesn’t develop in a uniform manner
From: http://www.hubrecht.edu
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Fluid PhysiologyAt Birth
Blood pressure increases - lambs Last weeks – increases 20%
During labor – increases another 18%
At birth – increases another 12%
Transmitted to capillaries Increased transcapillary filtration
Poor precapillary tone
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Fluid PhysiologyAt Birth
Other reasons for fluid shifts Direct compression of the fetus
Increased venous pressure
Vasoactive hormones Arginine vasopressin
Norepinephrine
Cortisol
Atrial natriuretic factor
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Fluid PhysiologyNeonates are Born Fluid Overloaded
Fluid shifts From fetal fluids / maternal circulation
Accumulating in the fetal interstitium
All Neonates Are Born Fluid Overloaded Rate of loss of this fluid - species variation
Foal – weeks
Other species 10-15% body weight rapidly after birth
Important not to replace fluid loss Poor outcomes with persistent fluid overload
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Fluid PhysiologyConsequences
Response to Hemorrhage
Response to Volume Loading
Response to Hypoxia
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Fluid PhysiologyResponse to Hemorrhage
Perinatal blood loss Rupture of umbilical vessels Premature placental separation Fetomaternal transfusion Fetofetal transfusion Internal bleeding
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Fluid PhysiologyResponse to Hemorrhage
30% loss of bloodAdult dogs, cats, and sheep
With out fluid therapy - 24 to 48 hours
Fetus or neonate is shorter Fetal sheep
2x adults within 30 minutes 100% blood volume within 3 to 4 hours
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Fluid PhysiologyResponse to Hemorrhage
Neonatal kittens and rabbitsGreater blood loss /kg before BP decrease
Translocation fluid and protein From the interstitial space
Tolerate blood loss better than adults
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Fluid PhysiologyResponse to Volume Loading
Rapid intravascular infusions crystalloids Fetal lambs - 6 to 7% retained at 30-60 min Adults – 20% to 50% retained at 30-60 min
Rapid transfer into the interstitial space High interstitial compliance High capillary filtration coefficient
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Fluid PhysiologyResponse to Volume Loading
Fluid Overload – lack of intravascular retention Adults (dogs, sheep)
The adult clears the fluid load hours
Renin
Vasopressin
Atrial natriuretic factor
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Fluid PhysiologyResponse to Volume Loading
Fluid Overload – lack of intravascular retention Neonates (puppies, lambs)
24 to 36 hr to clear fluid load
Volume load escapes vasculature space quickly
Escape volume sensors detection
No diuretic response
Urine flow rapidly returns to normal Before clearing volume load
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Fluid PhysiologyResponse to Volume Loading
After fluid loading (fetal lambs, neonatal lambs) Increase thoracic duct lymph flow
Increase by 3.5 times (max flow rate)
Angiotensin II augments lymph flow
Fluid therapy – rapid infusion Increases CVP
Dramatic decrease in lymphatic flow
Result in edema
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Thoracic Lymph Flow
From: Brace RA et.al.
Fetal lamb
Adult sheep
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Thoracic Lymph Flow
Fetal lamb
With large volume
intravenous infusion
↑↑ Lymph flow as much
as 340%
Limited by CVP
From: Brace RA et.al.
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Fluid PhysiologyResponse to Hypoxia
Moderate/severe hypoxemia (fetal lambs)
Increases arterial and venous pressures
Poor precapillary tone
Increase capillary pressure
Greater fluid shift interstitial space
Leading to excessive fluid overload
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Fluid PhysiologyResponse to Hypoxia
All neonates
Fluid overloaded at birth
With hypoxia/asphyxia
Greater degree of fluid overload
Hypovolemic with concurrent fluid overload
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Renal Physiology
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Renal PhysiologyRenal Maturation At Birth
Nephrogenesis is Complete, GFR adult levels in days Lambs Foals Calves
Nephrogenesis continues 2 + weeks Puppies
?? Kitten Kid
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Renal PhysiologyNeonatal Puppy Renal Function
Low GRR Low renal plasma flow (RPF) Low filtration fraction (FF) Decreased tubular reabsorption
Amino acids
Phosphate
Exaggerated proximal tubule natriuresis Balanced by increased distal tubule Na reabsorption
Low concentrating ability
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Renal PhysiologyNeonatal Cr & BUN Levels
BUN Lower than adults
Dependent on nutrition
Cr level at birth Cr lower than adult
Puppy
Adult level at birth
Infant - increase first 48 hr then decreases
Higher Cr than adult at birth but rapid drop
Foals
Calves
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Renal PhysiologySea of Cr – Fetal Foal
CrCr
Cr
Cr Cr
CrCr
CrCrCr
CrCr
Cr
Cr
Cr
Cr
Cr
CrCr
CrCr
CrCr
CrCrCr
CrCr
CrCr
CrCrCr
Cr
Cr
CrCr
Cr
Amnionic Cr9 – 12 mg/dl
Allantoic Cr120 – 180 mg/dl
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Renal PhysiologyRenal Perfusion
Fetus - 3-5% of cardiac output Birth rapid increases to 15%
Increase in BP Renal vascular resistance
Increases modestly But less relative to other vascular beds
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Renal PhysiologyRenal Perfusion
Autoregulation Normal range for age “Autoregulatory range” increases as BP increases
Puppies GFR/RPF increase in parallel with
Increases in BP Decreased in VR
Not changed by inhibition of angiotensin Until 6 weeks old
Foal, calf and lamb GRF becomes adult-like Independent of increases in arterial BP
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Renal PhysiologyNeonatal Vasogenic Nephropathy
Balancing BP and renal VR Vital for proper renal function
Neonatal Vasogenic Nephropathy (NVN) Abnormal levels of vasoactive substances
Increased sympathetic tone
Prostaglandins in neonates Afferent arteriolar vasodilation
Counterbalancing endogenous vasoconstrictors
High PG activity is physiologically necessary Maintain renal perfusion
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Renal PhysiologyNSAID
Greater potential for adverse renal effects Reduce GFR and RBF
Neonatal Vasogenic Nephropathy
Oliguria
Fluid overload
Both COX 1 and COX 2 inhibition equally bad
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Renal PhysiologyHypothermia
Rabbits decreases temperature 2 C Induce renal vasoconstriction
Decrease GFR
Hypothermic neonates at risk Environmental temperature at birth
Sympathoexcitatory response
Response occurs before a decrease in core temperature
Reversible with rewarming
Mediated by cutaneous cold-sensitive thermoreceptors Not core temperature
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Renal PhysiologyNephron Development
Number of nephrons
Great variation in normal individuals
Linear relation with body weight
Normal and compensatory renal growth
Primarily proximal tubular mass
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Renal PhysiologyNephron Development
Decrease nephron numbers Intrauterine growth restriction
Perinatal asphyxia
Shock
Exposure of the fetus to maternal administration NSAIDS
Glucocorticoids
Aminoglycosides
Beta lactam antibiotics
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Renal PhysiologyTubular Function
Immature at birth Low carrier density
Short tubules
Puppies Urine specific gravity
Birth is limited (1.006 to 1.017)
Adult levels 12 weeks (8 weeks kittens)
Protein, glucose, amino acids in the urine Neonate
Adult levels by 3 weeks
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Renal PhysiologyTubular Function
Large animal neonates urine specific gravity Broad range within 24 hours 1.001 to > 1.035 Herbivore Milk diet
Usg < 1.004
Foal First urine
12 hours, Usg > 1.035
24 hours Usg < 1.004
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Renal PhysiologySodium Story
Positive sodium balance needed for growth Increase interstitium Bone growth
Fresh milk is sodium poor Mare’s milk – 9 to 14 mEq/L 20% milk diet – 1.9mEq/kg/day Growth requirement 1 mEq/kg/day
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Renal PhysiologySodium Story
Immature kidney Na reabsorption With sodium loading in dogs
Proximal tubule – 64% adult dog: 48% puppy
Distal tubule – 26% adult dog: 51% puppy
Total – 91% adult dog: 98% puppy
Upregulation distal tubular Na transporters
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Renal PhysiologySodium Story
Slow to respond to Na load Species dependent Predisposes to Na overload Problem in critically ill neonatal foals
Crystalloid fluid therapy Na overload Fluid overload Limited urine dilution
Puppies Neonatal Vasogenic Nephropathy
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Cardiovascular Physiology
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Cardiovascular PhysiologyAt Birth
Increase in Arterial blood pressure Heart rate Cardiac output
4X higher than adult (lamb)
Regional changes blood flow Initially retains low-resistance–high-flow system Renal 3% to 15% at birth
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Cardiovascular PhysiologyNeonatal Changes Puppies
SBP 61±5 birth to 139±4 at 4 wk HR 204±3 at birth to 123±6 at 4 wk
Large animal neonates Studies confounded by restrain artifacts Clinical experience – low BP/VR to high BP/VR
Most make a rapid transition
A few neonates retain the low BP/VR maintain excellent perfusion
Critically ill neonates more likely delay transition
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Cardiovascular PhysiologyNeonates
BP cannot be used as surrogate for perfusion
Absolute BP numbers - Dangerous therapeutic goals
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Cardiovascular PhysiologyAutonomic influence heart rate
Puppies, kittens Sympathetic innervation functionally incomplete
Puppies – less chronotropic response
Lack of vagal tone - minimal response to atropine Puppies < 14 days Kittens < 11 days Atropine not effective in neonatal resuscitation
Clinical observations in foals, calves, crias, lambs and kids Autonomic cardiac control at birth Calves, crias
Intubation my induce dangerous bradycardia
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Cardiovascular PhysiologyResetting baroreflex
Baroreflex sensitivity changes with maturation Resets - shifts toward higher pressures Shifts during fetal life Shifts immediately after birth Shifts during postnatal period Paralleling BP increases
Resetting complex Peripheral resetting
Level of the baroreceptor
Central resetting Sympathetic or parasympathetic activity
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Cardiovascular PhysiologyResetting baroreflex
Puppies Baroreceptor reflex absent until 4 days of age
Large animal neonates Most make rapid transition
Some critically ill neonates Retain the fetal baroreceptor set point
Apparent inappropriate bradycardia
Low BP
But good perfusion
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Cardiovascular PhysiologyAutonomic Dysregulation
Critical neonates Transient but requires careful management Not respond adrenergic support Not vagally mediated
Not respond to atropine
May respond to oxygen therapy
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Cardiovascular PhysiologyDuctus Arteriosus, Foramen Ovale
Functional closure 50% by 24 hr 90% by 48 hr
Anatomic closure Within weeks Until they – powerful survival tool
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Cardiovascular PhysiologyDuctus Arteriosus, Foramen Ovale
Pulmonary hypertension Hypoxemia Sepsis
Consequences of Pulmonary hypertension Adult – Hypoxia Ischemia Neonate – Hypoxia without ischemia
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Gastrointestinal Physiology
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Gastrointestinal PhysiologyDevelopment Small intestine - first 10 days of life
Increases 80% in length
Increase 30% in diameter
Maturation is incomplete until after weaning
Macromolecules transport IgG, cytokines, trophic hormones, others
Gastric acid secretion not occur during transport period At least 24 hours
Rat - acid secretion not occur until weaning
18 days after birth
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Gastrointestinal PhysiologyDevelopment
Macromolecules transport Fetal intestinal epithelial cells
Transport macromolecules Some species neonatal epithelial cells
Life span 3 weeks Lambs – 5 days after birth
Calves – 14 days
Pigglets – 21 day
Transport slows by 6-12 days
Nonselective pinocytosis some species Reason for frequent translocation of bacteria?
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Gastrointestinal PhysiologyDevelopmentTrophic signals Luminal
Amnionic fluidColostrumFresh milkFoodNutrientsMicrobes
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Gastrointestinal PhysiologyDevelopment Trophic signalsCirculation/ local
Peptide growth factors Gut origin peptide hormones Steroid and thyroid hormones
Neural inputsCNS Enteric Nervous System
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Gastrointestinal PhysiologyDevelopment
Importance of luminal nutrition “Trophic feeding”
Growth and metabolism of mucosal cells Release of local growth factors Release of gut hormones Activate neural pathways (ENS)
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Gastrointestinal PhysiologyDevelopment
Fresh colostrum Fresh milk Mucosal barrier and immune function Establish normal flora
Flora is trophic Discourages establishment of pathogens
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Confused?