Beruflich Dokumente
Kultur Dokumente
At a glance
Author
Dr / Ali Abdel-Hakam
Computerized By
Dr / Noha Mokhtar
Dr / Ola
Allam
Dr / Mai Ghanem
Mohamed
Dr / Mervat Fathy
Dr / Randa
Dr / Ahmed
Khatab
1
Dr / Ahmed El-kalashy
Omar
Dr / wagdy Assar
Dr / Ahmed
Dr / Ahmed Ez-
Eldeen
Dr / Amr Gamal Soliman
Sorour
Dr /Ahmed
Special Thanks to
Dr / Ahmed Abdel-Hakam
)
Patients trust doctors with their lives and health. To justify that trust you
must show respect for human life and you must:
You are personally accountable for your professional practice and must
always be prepared to justify your decisions and actions.
Author
.
Special Thanks to
Dr / Ali Abdel-Hakam
Dr / Noha Mokhtar
Dr / wagdy Assar
Dr / Ahmed Sorour
3
Lecture
History
Examination
The Report
I.V. Fluids
G I ratio
Blood & Plasma
Dehydration
Feeding
Drugs
Sets
Post vent. Care
A,B,G notes
Full & Preterm Sings
During your shift
Nursing care
Respiratory distress
HMD
Broncho-pulmonary
dysplasia
Meconium aspiration
syndrome
TTN
Pneumonia
Pulm. Hemorrhage
Pulm. Hypertension
Pneumothorax
Neonatal cyanosis
Apnea
Page
1
3
5
6
10
11
13
14
21
29
30
31
34
36
37
38
39
41
42
44
45
46
47
48
51
53
Lecture
Page
CPR
54
Vomiting
55
Diaphragmatic hernia
56
Infant of diabetic
56
Mother
Prematurity
59
I.U.G.R.
61
Jaundice
61
Neonatal convulsions
69
CNS Infections
71
UVC
72
ETT
73
Hyperglycemia
75
Hypoglycemia
76
Hypocalcemia
78
Hypotension & Shock
78
Hypertension
79
Hyperthermia
80
Hypothermia
80
81
Poor perfusion
82
Tachycardia
82
Bradycardia
82
NEC
83
D.D. of tense Fontanels 83
I.C.H
84
Edema
84
Down Syndrome
85
History
(Done in 1st report)
1)
2)
3)
4)
C.S.
1-
Why??
e.g.
- Pre-eclampsia
- Heart disease
- D.M.
- Obstruction
- PROM +
11)
Presentations by :
- Respiratory distress , grads :
I. >>Tachypnea
II. >> I + Retraction
III. >> II + Grunting
IV. >> III + Central Cyanosis
- Jaundice
- Meconium aspiration
- Pneumonia
- convulsions
7
12)
Report :
-
- \
- ,
- :
: ----- :
1- Nasal : maximum 2 L \ min
2- CPAP : ---- %
3- IMV ( Intermittent Mechanical Ventilation )
4- A\C ( Assisted ventilation )
5- SIMV ( Synchronized IMV )
- :
Examination
1) General :
1. Look for appearance :
- Large baby IDM
- Small baby IUGR or Preterm
2. Colors :
- Pallor ( in lip , nails esp. if cyanosed as the blue color mask pallor)
- Jaundice ( in the body better than eye )
8
2) Head :
1. Shape of head : microcephaly , macrocephaly ( hydrocephalous )
Centile chart
2. Fontanels :
- opened or closed
- Normally: Ant. 2 cm & Post. Closed
- Bulging fontanel : CNS presser esp. if with convulsions
(IC hg, encephalitis, hydrocephalous)
- Depressed : indicate dehydration
3. Face : colors
4. Dysmorphic features : cleft lip or palate
5. Suckling : good or poor
Chest -3
Rate counted / 1 min , as neonate has cyclic respiration Don't count RR after suckling , due to there is some exertion with )
( tachypnea which disappear after few minutes
Symmetry between 2 sides ( no bulging or depression ) 9
Signs & Grades of RD ( I , II , III , IV ) Auscultation : air entry in 2 sides equal or not ( listen at MCL & MAL ) & presence
of additional sounds as Wheezes or Crepitation
Don't forget grunting :- listen to his voice -
Abdomen -4
a. umbilicus: if there is signs of infection or not as it is important
source of
.infection
b. distention
c. liver and spleen palpation
.d .intestinal sounds : if heard ,suckling is allowed
:Genitalia -5
to exclude congenital anomalies, examine both testes and anus to
.exclude imperforate anus
Heart -6
S1,S2 murmurs (may not be present in the 1 st three days even with congenital heart)
bradycardia ,tachycardia blood pressure capillary refill time (for perfusion) sepsis .... sternum
Sepsis -7
10
:Clinical picture
hypothermia or fever.1
decreased activity :very important .2
hypoglycemia due to hypothermia and the reverse is true .3
decreased motility.4
system impairment (score >3) (every item take one ) .5
A .Heart: tachycardia or bradycardia (<120)
B .Renal : oliguria
C .Respiratory : tachypnea , bradyapnea
D .CNS : convulsions ,lethargy, DIC and disturbed level of
.consciousness
Cannula-8
. Extravasation ,tissue necrosis with Ca
. Edema : you will find place of cannula either blue or red
. UAC
Investigations(routine): -9
CBC
- CRP
- Chest X-ray
- ABG -
limbs -10
A . tone :frog leg , flaccidity
B .edema in lower limbs :give lasix and plasma
11
Reflexes : the most important reflexes are Moro and suckling -11
reflexes
: Skin -12
.A . pinch for dehydration if on phototherapy
.B . press : if perfusion > 3 sec delay , give dopamine
C . sclerema >>>> sepsis
D . ecchymosis >>>> anemia ,PT
Normal examination
CNS: Good general conditions , Active cry , Good suckling , +ve
Moro reflex
Respiratory: Equal air entry bilaterally , No adventious sounds
CVS : Normal S1,S2 , No murmurs
GIT : Lax abdomen , No organomegally , Intestinal sounds
Report
Items
: history.1
D/D-
/
12
Male or female
delivery
IV fluids
13
( )
: Indications
all sick babies
blood sugar
4- RD ( R.R >80 or -3
6- dehydration -5
: Solutions
dextrose: 5% - 10% - 25% ( 5% means 100 c.c >>>>5 gm ) -1
normal saline : ( Ns ) .9% .each 100 ml has 15.4 mEq Na & -2
15.4 cl& .9 Nacl
Kcl (potassium chloride ): ( 15% 1mmol for each 100 ml fluids ) -3
Ca gluconate 10 % >>>ca -4
neo/ment : in < 30 day -5
glucose 12 % (12.5% )
-No Ca
- saline
-potassium -
: When to discontinue
( 3 / 20 -)
has adequate calories intake & fluid by nipple or tube feeding ( -1
120 ml /kg/day)
has recovered from an illness-2
no longer needs I.V for glucose -3
15
( )
4-hypoxia
2-preterm -1
5-perinatal asphyxia -3
NB: ca is withdrawn if HR<120Amount: ( according to weight )kg >>> 90 ml /kg /day 2> kg >>>> 80 ml /kg/day 2.5 - 2 kg >>> 70 ml/kg/day 3 2.5 kg >>>> 60 ml/kg/day 3 < -
-2.
-1
Net fluids **
NF ,, (( - ((Aminovein
-Neoment
- Dormicum , dopamine or any drugs which is add to solutions
rate 24 -: TF ( total fluid ) = ( this is the amount that enter circulation )
Dr ( drugs ) = .. Calculate the total amount of drugs for this day
Feeding = .. the total amount of feeding for this day NF ( net fluid ) =.. include neoment + aminovein + drugs on them
17
-: **
line iv Ex: we give iv fluids by rate 6cc/hr & give plasma by 10cc/hr for
, 24hr so in 2hr we give 20cc plasma& 12cc iv fluids so
= cc 8 = 12 20
: stop it in
feeding 15 cm/3hr
2- renal problems( due to increased -1
protein)& use plasma here
:Dose
Start with 0.5 gm/kg/day or 1gm (the best ) or 1.5 gm ( different
schools )
Max. dose ) ( , 0.5gm/kg
FT >> 3gm/kg/day
PT >>3.5/kg/day
X 10 X =
NB:- Concentration of aminovein 10 cm / 1 gm
..... 3/ 15 line ..... 3/20
18
Restriction
*: in case of ( TF X 0.8 ) 20%
19
Chest(RDS - meconium aspiration - pneumothorax) in case of: IC Hge - Cardiac (overload) ( TF X 0.7 ) 30%*
hydrocephalus CNS
renal -(brain edema> tense fontanel)
: sepsis*
dry tongue-1
suken eye-2
depressed fontanel-3
pinch test which is-4
inaccurate in PT as there is
little or no SC fat
poor feeding-1
hypo or hyperthermia-2
hpo or hyperglycemia-3
hypoactivity-4
hepatomegally-5
sclerma-6
jaundice-7
DIC-8
Addition
1-10%for each photo ( so double >> 20 % )
restriction
extreme low birth weight >> sepsis dehydration -2
NB:- To calculate 120 % >>> multiply TF * 1.2
?Why restriction
In previously mentioned cases there is SIADH (syndrome of
inappropriate ADH secretion) >> increase ADH >> fluid retention
by 10-20%
? Shock therapy
20
J
Glucose Infusion Ratio ( GIR )
24
:
or
- Normally : GIR = 4 8 mg \ kg \ min
Maximum is 12 , Minimum is 4
- Uses in cases of hypoglycemia & hyperglycemia
- In hypoglycemia :
12 12 GIR
Corticosteroids hypoglycemia
- In hyperglycemia :
4 GIR
Insulin hyperglycemia
- N.B.
Sepsis hyperglycemia
Canula hypoglycemia
Sepsis
- Now the question is how to control GIR ?
By changing glucose concentration (eg. Replacing G 10% by G 7.5%)
Rate
To avoid volume overload
21
- Indications : ()
1- Sever sepsis ( as it contains Ig ) ,
2- bleeding tendency
3- Edema ( osmotic effect ) every 12 hr if sever
- Dose : 15 ml \ kg \ dose
- ( ) \ 3 2
- e.g. >>> Request
15 3-2
N.B.
- Whole blood ( ) 20 ml \ kg \ dose
- 6 4
6
- After blood or plasma , we need to :
1-Measure blood pressure
2-Give lasix to decrease overload ( 9 + 1 )
N.B.
- Challenge test ( preterm no urine + edema )
22
If patient with no urine :give fluids ( shock therapy or plasma ) then lasix within 20
min then see urine out put :
If +ve pre renal failure ( hypovolemia and so measure the BP )
If ve renal or post renal causes
N.B.- Plasma given if aminonein Is contraindicated esp. if urea & creat
Also if plasma is given stop aminovein for that day.
- Indications :
1- Ideal for who requiring red cells not volume .
2- O2 carrying capacity of blood in a cutely in infants with sever RDs & on
IMV .
3- Try to maintain HB > 13 gm \ dl .
4- Cardiac patients ( cyanosis , HF ) .
5- Symptomatic anemia ( tachypnea , apnea , tachycardia , bradycardia ,
feeding , lethargy , pallor ) .
Fresh Frozen Plasma :
- Indications :
1- Replace clotting factors TTT of shock .
2- Dilutional exchange transfusion .
3- Sepsis DIC .
4- Premature .
5- Sever RD , coagulation disorders .
No cross matching or ABO compatibility is needed for the plasma.
Both warmed to 37oc before transfusion , But by blood warmers not direct heat to
avoid Agglutination .
23
Dehydration
Types of dehydration Therapy :
Dry Tongue
Depressed Fontanels
Fever
Hyperglycemia
Decrease urine out put
24
Feeding
Types of feeding :
1) Enteral nutrition :
- Breast feeding
- Bottle feeding
- Tube feeding ( Gavage feeding )
2) Parental feeding
Enteral nutrition :
- Types of milk :
1) Breast milk
2) Expressed breast milk
3) Standard formula
4) Premature formula
5) Special formula :
- low phenylalanine ,
- low phosphate ,
- S26AR
N.B. Calories :
-To maintain weight & essential body functions , The baby needs 50 60 Kcal \ kg \
day.
-To induce weight gain .
Full term give 100 120 Kcal \ kg \ day , Preterm give 110 140 Kcal \ kg \
day .
-Formulas :
ordinary 100 cc 67 Kcal
Kcal \ kg \ day =
25
26
Action
Dont feed till you pass a tube into the
baby stomach to exclude esophageal
atresia .
Insert NG or OG tube & withdrawal air /
fluid to decompress the babies stomach ,
dont feed till rule out obstruction Or
illus .
Dont feed by bottle nor allow breast
feeding until RR is about ??? & the baby
can co-ordinate suckling , swallowing ,
breathing .
Feed by NG or OG or IVF till tube feeding
can be administrated .
Stop feeding & obtain Abdominal X-ray to
evaluate for possible I.O.
Stop feeding until you evaluate for
obstruction .
Keep NPO till baby is stable for 24-48 hr
till bowel sounds appear to avoid NEC &
renal pr. .
Remove NG tube , give bolus feeds by OG
tube .
Suspect sepsis . NEC or intestinal
obstruction .
Decrease the volume of next feed &
more gradual , use jejunal route
Tube feeding : NG or OG
27
3- For certain sick babes : > 34 W with certain conditions that prevent them from
being fed safety with nipple :
* Severe neurological problems : with absent gag reflex
* Babies who tires easily from exertion from nipple feeding
4- Babes recovering from RD but still tachypneic ( RR > 60 Br. / Min. )
The infant developed gag reflex & can coordinate suckling , swallowing &
breathing
- No respiratory problems
2- when they are not tolerated : significant residual volume is found consistently
before each feeding or if bile appears in residual stop tube feeding start IVF and
investigate the case
3 if respiratory distress is increased : RR > 90 Br. / Min.
Complications
1- Malposition : tube to airway
2- Over & under feeding
3- Perforation of esophagus , stomach or ulcer at mucosa
) (
28
Clinical application ()
When to
start
1- When to start ?
-Usually , not in the first day
-usually Not in infant on IMV or CPAP(some prefer to start
feeding on IMV &
CPAP)
-When respiratory distress resolves
(( RD >> no feeding for fear of aspiration ( As swallowing reflex
and respiration are
still not coordinated ) . ))
2- Method ?
- 1st by Ryle then by suckling (when to shift >> see N.B. )
3- Dose ?
A) Full term baby :
-Start trophic feeding : 3 / 5 ( fixed )
29
Clear
2 11 11 99 77 55 -
Full dose 30 cm / 3 h r
) (
5 3 /
) ( ml / kg / day 15 10
8 3
)) fixed
: 8
.....
fixed
Tolerate easily <<<< GIT
KG
1.5 -1
B) preterm
NEC -
clear gastric wash 2 6 / ) 1 ( -
2 3 / 2 -
2 6 / -
-
30
: Ca 15 3 / < -
20 3 / <
canula
rate
30 3 / < + -
) 4) Drugs :- (Prophylactic
> H2 blocker
Zantac
) )
> 10% (or
No residual
Continue as
)20%
)20%
the regimen
+
)
(
N.Bs
) 1
-NG residual with Ryle
10 3 / Suckling is good
RR 60 90 Ryle
RR < 60 oral
feeding
3 / 30
(Full amount )
- <
- > << gain weight
* Calculate needed caloriesusually the range between 120
150 K. Cal/ kg/ day
* Take e.g. we now want to make 2 KG baby gain weight using
150 Kcal/ kg/ day:
1- K.cal / day = 150 X 2 = 300 K cal
2- K.cal \ 100 cm 100
cc > 67 K.cal
3-
100 >> 67
??? << 300
33
8 4-
K.cal / Kg -:
so 30 X 8 = 240 cc/day
30 cc / 3 hr
100 >>> 67
??? >>> 240
<
K.cal -:
K.cal ) 1 _.5 ( 1 = 40
30 3 / 5. ) (
-: 1 ..........
_5
_6_ 4
Drugs
Antibiotics :A) uses :
1- any invasive procedure eg canula
& 2- when to start immediately :- e.g. - history of PROM > 24 hr
we give triple
antibiotics.
C) Duration :( ) = +
CRP ve
Lines of drugs:-
35
NB :- Another regimen
1st line :- Ampicillin & garamycin
) 2nd line :- unasyn & fortum ( we can't add amikin as it nephrotoxic
3rd line :- Vanco & fortum
4th line :- Vanco & Meronam
5th line :- liquid penicillin & ceftriaxone
) X X ( =
150 m g /
kg / day
375 8.3 /
2 3
750 16.6 /
12
8
1500 /
33.3
40 20 10
14 10
7.5 mg /
kg / dose
) (gram ve
36
2 / 100 7.5 /
12 /
24
1.2
1.2
12
-This drug is nephrotoxic so not given more than 7 days & not
given more than 7 days & not given in renal or pre-renal failure
e.g. generalized anasarca
If used > 7 days > asses renal functions (UREA & CREAT.)
12
500 10 /
12
100 mg / kg
/ day
:
X 3 / 500 100 /
8
15 mg \ kg \
dose
X 4
8
500 100 /
20 mg / kg /
dose
37
)
(
12
200 100 /
10 mg / kg /
dose
Antiviral
5 /
% 5
10 mg / kg / dose
= 400
2 / 20
5 7.5 mg / kg /
day
2 / 80
12
100 mg / kg / day
10
500 10 /
/
24
24
5 / 100
24
oral
) ( macrolides 200 5 /
)(once
Gastric
wash
10 mg / kg / day
- Given for 3 5 day only & oral as it accumulates in tissue
- Used for atypical infection
11
7.5 mg / kg / dose
% 5
24
( once )
5
2 1 /
%
12
( nystatin )
6 mg / kg / day or
dose
Anti fungal >
Vent 7
12
12 / 500 10 /
13
100 mg / kg / day
(4 /)
14
Vial / 10
Vial
=1000000 IU
100,000 IU / KG /
day
CNS infection
200,000 : 300,000
IU/kg /day
Infusion
- renal 200 5 /
dose
18
- cardiac
36
15
-Renal dose : 5
micro / kg / min
-Cardiac dose : 10
micro / kg / min
15
V.C dose in
(Severe
39
hypotension,septi
c shock )
N.B.
- acts mainly on heart for ( hypotension , hypoperfusion , brady < 100
+ good sat )
- withdrawal gradually
- if HR > 150 >>> dont give cardiac dose
- dopamine VC dose ( 15 ) in hypotension
- given to improve perfusion > (( How to know defective perfusion ? ))
>> mottling ( indicate decreased perfusion & acidosis hypoxia ) +
>> Pallor
---- test of perfusion >>
.. 3 2 1
wt (?) X dose (5) X dil. (5) X 24 X 60 (min)
(micro)
X 1.44 ( 24 X 60 ) / 1000
1044
250 5 /
16
12
100 1 /
12 /
1 + 9 ( 1mg / kg / dose
)
1mg /
kg / day
/
12
17
10 1
1
1 10
1
4 1 /
( )
(1+9).
0.15 mg / kg / dose
0.4 >< 1
But :0.25 mg / kg /
dose
+ 1 )
( 3
1
8
1
9
2 mg / kg / day
1 / 25
2 12
.)(1+9
12
1 <>
2.5
1 cc / kg / dose
% 5 +
5
%
- brady
- Na bicarb ) (
Cautinous. necrosis - DM , preterm , hypoxia
15 3 / ) - CVP ( central line
Hypo Ca double
2
1
1 cc / kg / day
)(vit K1.
<> 10 1
24 8
.)(1+9
12
1 <> 1
2
12
24
preterm FT -
42
IM
12 + + gastritis + -
22
12
12 / 0.25
Active bleeding
23
2 / 10
) 0.3 mg / kg / day
) 0.5
1+9
Iv slow or 12
per oral
24
1 <> 0.5
Cortigen B6
)
-
Vomiting , colic ( cry ) , bring leg to abdomen
- side effects : extrapyramidal if overdose so give cortigen b6
24
8 / 5
Given in distention
prophylaxis
25
1.5 cc / kg / day
1/3 8
8
26
43
1 / 25
Loading : 5 mg / kg
/ dose
. )(1+9
1
2.5 ,
M
8
Maintenance : 2
2.5
mg / kg / dose
( every 8 hr. )
12
L = 1.5
cc / kg
M (if 5mg
/ dose ) =
Weight /4
every 12
hrs
40 /
1
(1+3)
.
1 <
10
phenobarb
Loading :
15-20 mg /
kg / dose
Maintenanc
e : 5 mg(38) / kg /
dose
12
27
L
10 - 20
M
1.2 - 2.4
(
)
-
5 1 /
(1+4)
.
1
1
10 )
(
(midazolam
)
Loading :
0.1 - 0.2
mg / kg /
dose
Maintenanc
e : 0.05 - 0.1
or 0.2 mg /
kg / hr
^
28
44
(1.) 10
20
(05.)
(2.) 5
x
24
shots
15 /
( safer )
7 /
+ 1
9<<<<<
+ 1
4<<<<<
29
- Keep your eyes on O2 sat. as it cause Hypotension - cardiac arrest respiratory arrest
- fight IMV
12
50 /
1
(1+4)
1
10
L = 15 mg /
kg / dose
M = 5 mg /
kg / dose
30
31
45
32
Oral drugs
A) oral antibiotics :- oral or by Ryle
Tab is 100 mg
- Others
24 / 5 ( ):
- 12 8 1 5 - Lactobacillus stimulating factor ,thus increase immunity
- given in PT as prophylaxix against NEC + gain weight
L-Carnitine
47
- 5 drops/24hours
Cetal drops
- 2 drops/kg/dose /6hours
Ointements
Thrombophob :- for contusion & sites of canula
Fucidin :- Antibiotic
Muconaz gel
- for oral fungal infection
- gel for mouth & tongue every 6 hours
- done with mouth wash by bicarbonate
Uses :
1 - Post-vent >>>
2 - chest problems >>>
48
5 : 1.5 + ) 5( - + ) (
secretion
2 : /
: 3 6 12
function : bronchodilator + decrease secretion ( salbutamol B2
) agonist
>
function: post vent > decrease vocal cord
)inflammation(vasoconstrictor
1 : 9 ) (
0.5 1.5 +
3 : 3
3 V.C.
>
function: decrease secretion & in wheezy chest ( as
bronchodilator ) , it is ipratropium bromide
5 : 1.5 +
: 12 ) 8 (
chest 1-
pneumonia
post vent ... 3 2-
chest 3-
49
4-
pulm. cort.
long acting bechlomethazone (inhaler )
neonate atrovent chest infection
4- post. vent
3 3 /
(ABG)
51
1 ) NORMAL FINDINGS :
PH : 7.35 7.45 OR 7.40
PO2 : 60 mmHg ( after clamping
umbilical cord )
PCO2 : 35 45 mmHg
HCO3 : 1822 mmol / L
or 20 26 mEq / L
BASE DIFICIT : BE (- ) = +2 : -2
2 ) INDICATION :
1 RD esp .(if PRETERM )
2 SEPSIS eg . pneumonia
3 severe diarrhea and vomiting
4 DKA
5 RENAL PROBLEM
6 ANEMIA
3 ) CASES WE FACE :
1 RESPIRATORY ACIDOSIS
2 METABOLIC ACIDOSIS
3 MIXED RESPIRATORY AND METABOLIC ACIDOSIS
** alkalosis is uncommon and usually is iatrogenic
NB : higher PH limits is desirable in the prescence of
hyperbilirubinemia since
acidosis esp. respiratory may potentiate encephalopathy .
4) COMPLICATION OF MARKED ACIDOSIS :
1 increase pulmonary vascular resistance .
2 inhibition of surfactant synthesis .
52
5 ) CAUSES OF METABOLIC
ACIDOSIS
CAUSES OF RESP
ACIDOSIS
1 - hypoxia
2 shock and hypoperfusion
( sepsis,HF ,NEC)
3 inborn error of metabolism
4 RTA
5 feeding acidosis in premature
- Asphyxia
- Apnea
- obstructed ETT
- bronchospasm
- pulm. Edema
- central hypoventilation
- Chronic lung disease
>>>>>>
ALKALOSIS
LOOK AT PH
ACIDOSIS
PCO2
HCO3
PCO2
HCO3
IF LOW
IF HIGH
IF HIGH
IF LOW
RESPIRATO
RY ALK.
METABOL
IC ALK.
RESPIRATO
RY ACID
METABOL
IC ACID
53
8 ) N.B
CLINICAL
As bicarb is acalculated data ( there is no electrode that measure
bicarb but the computer calculate it from PCO2 , PH
PH PCO2 ,
9 ) MANAGEMENT :
1 RESP. ACIDOSIS
If unventilated
ventilated
2 METABLOIC ACIDOSIS
Correct bicarb
( criteria )
if failed
ventilation
3 MIXED CASES
1 don't give bicarb ist as it will give co2 inside the body(practically we give
it together with increasing co2 wash)
2 correct resp. acidosis 1st by increasing vent . rate
3 then give bicarb
54
So we give :
30 15 % 5 +
N.B maximum dose : 10 Na bicarb
2 10 ....
(Na + K ) ( Cl + HCO3 )
It is arrange between 8 : 16 mEq/l
Bicarb Bicarb
PRETERM < 37 W
SOLE
Crease is complete
Very PT has no
creases and increase
by time
Genitalia
Male : undescended
testis
Skin without rugue
Pigmentation
Present
Faint areola
No bud or nipple
Ear
Normal
Thin
No cartilage , No
recoil
Skin
Thick no veins
Thin red
apparent veins
Lanugo hair
No
Fine hair
:
1 1 day glucose 10 % or 7.5
nd
2 2 day neoment + rest or add +Ca
3- you can add aminovein from 3rd day & written with solutions
4- 12
4 ( + )...... 4
5- ( ) 24
6- .....
7 - increase by 10 ml / day till 150
st
:
(1)
(2)
57
)(3
7 ,
)Write with drugs that have loading and maintince >> L , M (4
) Preterm , asphyxia , IDM) 5
)Total dose (6
)Aminophyline .. after vent and for premature (7
) Gradual) 8
:
Ca 15 3 1-
20 3 2-
30 3 3-
..... 4-
2 3 jaundice 5-
58
** general **
*Colors ( pallor , jaundice , cyanosis , mottling , capillary refill )
*activity
*temp
*BP
*Weight
** chest **
*Auscultate :- air entry + additional sounds
** Heart **
*S1 , S2
*HR
** Abdomen **
*Distension HSM
** Investigations **
*CXR RBS-ABG
** Recommindations **
59
- RR
- Color
-Saturation
- Feeding
- HR - In IMV >>
auscultate Tube
1 check temp of incubators
2 if photo :
*check fluids ( rest/ add)
*distance numbers of lamps
* ...
3 O2 :
*nasal : fitted or not
* CPAP :
1- Percentage ?? >> if more 70 % and the neonate still unstable shift to IMV
2- tube >> hear , aspirate
* IMV : - setting
- FiO2 . Decrease gradually if there is improvement
- Tube . If obstructed , change
- auscultate chest
4- Solutions
Check rate type of solution
Rest / add aminovein
5 feeding : distension vomit
6- drugs :
AB
Dopamine
HR
7- investigation : done or not
8- chest examination >>>>> apnea , preterm
9 abdominal examination
10 vitals
11 special care for each case
60
. . 3 / 3 -
12 -
-
-
: - -
: -
: -
-
-
-
RESPIRATORY DISTRESS
61
CAUSES :
1) RESPIRATORY : respiratory distress syndrome MAS pneumonia pneumothorax airway obstruction as Bil . choanal atresia - bronchopulmonary
dysplasia
2) CARDIAC : HF PDA PP HTN
3) CENTRAL : HIE IC Hge meningitis
4) HEMATOLOGICAL : severe anemia polycythemia
5) OTHERS : sepsis hypoglycemia metabolic acidosis - hyper / hypothermia
D hernia
APROACH TO DIAGNOSE :
A ) HISTORY :
1)PRENATAL : any disease of the mother befor birth leading to hypoxia ,
Maternal
drugs , previous baby with RD
2) NATAL : PROM fetal distress obstructed labor AF (meconium staining )
3) POSTNATAL : APGAR resuscitation time of RD TTT Given
B) EXAMINATION :
1) Grades
2) chest auscultation
Grades :
Grade 1 : tachypnea 60 Br / min
Grade 2 :retractions ( interscostal subcostal suprasternal )nasal flaring which
represent attempt to decrease airway resistance(air hunger)+ pursing of lips
o2 saturation
2 CARDIAC : HR BP pallor anemia
3 activity
sepsis
4 investigation
5 change position ( ventilation ) suction
6 physiotherapy
2 prenatal asphaxia
4 C.S
3) RBS
63
Def. :
is a neonatal form of chronic pulmonary disorders that that follows a primary
course of respiratory failure ,
e.g. RDs - MAS in the 1st day of life .
also defined as persistence O2 dependency up to 28 days .
Incidence :
is more in ELBW infant < 1000 gm
1234-
2- Examination :
- Skin , nail , umbilical cord meconium stained
- Lung over distention + bowing of sternum ( AP diameter )
- Auscultation Ronchi + Crepitation
3- CXR :
- Over expansion multiple atelectesis
- Opacity pneumonia
- Pneumothorax , pneumomediastinum
4- Lab . : ABG
5- Echo : for PPHTN
* Treatment
A) Prophylactic : Better & recommended
When head is delivered and before respiration stimulation
suction of mouth (1st)and nose very well &wrap baby with
heated towel to prevent respiration and intubate &suction of
trachea +O2
B) Curative : TTT of problems
1
)) Respiratory distress :
, make inspire 3
67
68
-Other names
Wet lung type 2 RDS
- It is common and resolve whithin 3:5 days (self-limited )
-Risk factors
- C.S &term baby
- maternal sedation ---delayed clamping of cord
- Prematurity
-maternal asthma
-polycythemia
-maternal
-Diagnosis
1- History
-Breech -
4- ABG :
- Hypxia , Hypercapnia , R. acidosis
-Management
1- Hypoxia : O2 therapy nasal or head box < 60% , CPAP may be
needed ,
Suction , Change position
2- Fluid , electrolytes feeding :- IVF 1st then ryle then oral , Rest
20% ,
Start feeding when RR < 90 by ryle, then when <60
oral & gradually
3-Antibiotics
4- Temp. control
5-Nursing
6-Monitoring
7-Discharging when :- RDS ( RR 50-60) is good , Oral feeding ,
No jaundice
, infection
Pneumonia
-Organisms :- Bacterial Viral Spirochetal Protozoal Fungal
-Routes :- Trnspalcental during delivery (GBS . Ecoli )
- Nosocomial (stph , strepr , GBS . Ecoli .)
-Risk factors
70
-Fresh blood
-RR BP Urine
NB :- Congenital pneumonia
1.RD early in life
3.Cyanosis
2.Tachypnea is high
4. Vent increase VR
5.CXR white lung
NB: IF you find opacity & You aren't sure , confirm by C/P
(tachypnea + retraction + all One lobe ) AS collapse give same
appearance on CXR but wz shift to mediastinum
Imp . Appearance of pneumonia
1) Lobar all one lobe ( homogenous )
2) Bronchial pneumonia patchy opacities
NB : TTT of collapse >> good physiotherapy &
NB: follow up of pneumonia by CXR & auscultation
P.Hge is a very serious sign that have very poor prognosis , So the
best management for P.Hge is PREVENT its occur .
Def. :
Gross bloody secretions are seen in the ETT ,
It occurs most commonly in acutely in infants on mechanical ventilation
between 2-4 days of age .
C\P :
The infant has sudden deterioration in respiratory status , suddenly becomes
hypoxic , sever retractions , pallor , shock , apnea , bradycardia , cyanosis .
72
Causes :
Hypoxia & trauma are the main causes
1- Usually direct trauma to the air way with intubation or vigorous suctioning ,
esp. if the suction catheter is out the ETT .
2- Also with coagulopathy ( DIC ) & bleeding from other areas is present .
3- Babies with large amount of blood transfusion ( over transfusion ) lead to
increase pulmonary capillary pressure , So P.Hge .
4- Congenital HF , pulmonary edema accompanies PDA .
5- RDs esp. after surfactant injections .
Management :
Again PREVENTION is the rule , how :
- The most common cause is delayed management of hypoxia esp. in premature
babies , So acidosis & prematurity lead to Hge .
- The aim is to correct hypoxia & acidosis from early by doing :
ABG & see if need to IMV , TTT of acidosis / CBC , CPR , Hct , coagulation
profile , PT , PTT
N.B:- CXR Hge may be focal ( focal , linear , nodular
densities ) or
Massive ( complete white out ) & also
may be clear .
- Auscultation tight chest .
Treatment :
I.
Emergency measures :
1- Suction the air way till bleeding subsides
2- O2 concentration
3- PEEP to 6-8 cm H2O ( tapenade of capillaries )
4- PIP
5- Give epinephrine through ETT (V.C. to pulmonary capillaries )
6- IMV
7- , , ,
8- Shock therapy
II. General measures :
1- Support & correct BP ( shock measures , colloids as plasma )
2- Correct acidosis
3- Blood & plasma \ 12 hr
4- Avoid excessive volume which lead to pulmonary edema
5- ABG
III. Specific measures :
1- If trauma surgery
2- If aspirated maternal blood usually no TTT , self limited
73
3- For coagulopathy HDN : vit K, fresh frozen plasma 10ml\kg\1224 hr , platelets & monitor coagulation profile .
N.B.
Pulmonary hypertension
Management : desataturation
1- Ambo bag & see what the baby need , observe rate & pressure till
saturation .
2- O2 demand by control temp. & if no IMV give proper sedation & gentle
handle & suction ( V.C. ) .
3- O2 delivery : see the proper route , up to IMV & FiO2 .
4- Correct acidosis : by Na bicarbonate even you did induced alkalosis ,
it help to oxygenation & PHTN .
5- Restrictions of fluids 30 % .
6- Vasodilator : ( ambo ) .
7- No indomethacin if suspect PDA , till you know is it dependant or not .
8- Inotropes ( Dobutrex ) to C.O.P. + Pulm. V.D. but BP ( it acts mainly
on blood vessels )
Pneumothorax
Def. :
Collection of air within the close cavity ( pleural ) .
Cause :
Rupture in lung tissue that may be spontaneous ,
If it sever may cause shift in heart ( mediastinum area ) .
Risk factors :
1- IMV : esp. in
- preterm(common)
- Assisted ventilation with RDs
- High PIP , longer time
- Slow VR ( rate )
- Baby fight with IMV , So by sedation or ms. Relaxant or shift to
assisted.
2- CPAP also ((6
3- Babies who required resuscitation with bag & mask or ETT(
)
4- Staph pneumonia ( abscess & rupture )
5- Meconium aspiration syndrome or blood or amniotic fluid aspiration , or
any aspirated material that cause ball-valve effect in airway small branches
esp if on IMV .
75
Complications :
1- Hypoxia
2- Acidosis
3- IV Hge due to decreases VR to the heart from cerebral veins , hypercarbia
and peripheral arterial constrictions .
Diagnosis :
I. History :
- At risk infant .
- Sudden deterioration in the ventilated baby .
- Case of cyanosis improved then deterioration with ambo .
N.B. Pneumothorax is an emergency case that need high level of suspicion
II.
III.
Examination :
- Inspection :
1- Cyanosis ( sudden )
2- R.R. or effort
3- One side become high ( of chest )
4- Abd. Distension ( as diaphragmatic is pushed down )
5- Apnea
- Palpation :
1- Deterioration of general conditions like mottling of the skin , sluggish
peripheral blood flow .
2- Trans illumination test .
3- Low blood pressure ( pressure in major veins prevent venous
return ) .
- Auscultation :
1- Breath sounds are louder over one lung ( not easily detected due to
radiation ) .
2- Shift of the heart beat ( ) and you think it is arrest as you don't
hear heart beats on apex.
3- Tachycardia (heart failure) then Bradycardia then arrest.
CXR :
- AP & Lat. View jet black appearance , shift of mediastinum .
- AP may under estimate the extent of pneumothorax .
IV.
-
ABG :
PCo2
PO2 & saturation
PH
Mixed respiratory & metabolic acidosis
76
Management :
1- Small volume , asymptomatic cases :
Observation & monitoring .
2- Emergency cases like tension pneumothorax :
Air must be aspirated by needle (butterfly) then >>>>chest canula >>>>.if
controlled >>>leave the canula till complete evacuation
-if not improved >>>>chest tube is needed.
3- Symptomatic infant who are in IMV may need chest tube insertion.
NB: pnemothorax is not an absolute indication for mechanical ventilation.
Needle insertion
forceps
Transillumination: - See your text
-: IMV
Change setting as follow :- PIP 22 : 26(some say decrease pip but
better to judge by saturation)
, Rate 60 : 70 , O2 100 % ,
Flow 10 , Time 0.38 ,
PEEP decreased to 3
: endotracheal
tube
Chest canula
1.Sterilization first
2.Insert canula in 4th or 5th space MAL or AAL(angle 45) till you
become below ribs then be horizontal thenpush towards same
shoulder under water seal till air appearance
Do not remove it never till x-ray show cure
Important: insertion above lower rib to avoid the (VAN)
After removal sterilize and cover wound
NB:the most sure sign of the corret canula is the oscillation of the
fluid level at the end of the line
78
Neonatal cyanosis
Def.
- Arterial saturation less than 90% and pao2 less than 60
- bluish app. Of lips and mucosal membranes
- Cyanosis is emergency and need rapid response
Acrocyanosis:
Hands and feets only are blue and is a normal phenomena after
delivery
-Black infant may show lips color that mistakes cyanosis
Central cyanosis :
-site :lips tongue conj. skin- extremities
Pao2 is low Extremities are warm and well perfused-
Peripheral cyanosis :
Site: extremities but tongue-lips-conj. Are pinkPao2 is normal- Extremities are cold poor refill time
How to manage
First see central or peripheral- Causes of central cyanosis(CC):
79
What to do ?
1- cyanosis
2- no air entry
3- no expansion
Chonal atresia , HT
murmur
81
Apnea
Def :cessation of respire.for 20 sec. or more (some say 15)
Or for shorter time if with bradycardia or cyanosis
Periodic breathing: a regular sequence of resp. pause ?? 10-15
sec. follwed by periods of hyperventilation and occurring at least 3
times /min with no cyanosis or bradycardia ????
Risk factors :
1.
2.
3.
4.
5.
6.
Apnea of prematurity
(needs continuous observation of premature baby)
Causes:
CENTRAL:
1. no signals from CNS to resp. ms (immature brain stem)
2. May be induced also by ryle deep suction reflux
OBSTRUCTIVE
1.
2.
Obstructed by milk or secretion
3.
Neck hyper extension
4.
Eye cover
MIXED
Same risk factors + or bradycardia
- The chance of apnea increased as birth weight decrease
- All prematuraties <1800 gm will have at least one apneic spell
- All babies <1000gm will hame apnea
- Usually begin in 2nd 3rd day if onset in second week think other
cause
- Also if onset in 1st day pathological
Onset of apnea:
- Within hours after brithmaternal drugs asphyxia
- Less than 1 week apnea of prematuraty-PDA- IC hge Post
vent
- >1 week ++I.C.T
- 6-10weeksanemaiof prematurity
- At any time sepsis-NEC .. (risk factors)
Mangement
Babies at risk you should do monitoring of
1.HR esp. >100 (set the alarm)
2.resp. monitor(alarm if >20 sec apnea )
3.oximeter (hypoxia)
TTT:
1.Tactile stimulation if no emergency on chest and feet
2.Bag and mask (begin with this step)
83
Conclusion
Lines of apnea
1. aminophylline
2.caffine cetrate 5mg /kg/dose(9+1) /24 hours (1cm > 20mg
so,after dilution 1cm >2mg )
3.CPAP
4.IMV ( NB > If IMV used > put low setting(why>>> to increase
CO2 retention and avoid O2 toxicity )
CPR
84
How to do CPR
function of external cardiac massage:
- Compress heart against spine
- ++ intrathoacic pressure
- Circulate blood to vital organs of body
- 2 people are required one to compress and the other to
ventilate
Technique 2(thumb or 2 finger)
(( Thumb tech. ))
:Adrenaline infusion
- 1 / 1 24 ..... % 5 23 +
-
Vomiting
1.intestinal obstruction
2.NEC (inborn error of metabolism )
3.sepsis(Pneumonia - UTI gastroenteritis
meningitis)
4.increased I.C.T
Investigations :- sepsis work up x-ray erect&supine barium
cranial US electrolytes Bicarb metabolic screen
NB:- You should compensate the loss + if severe >> NPO
Diaphragmatic hernia
Diagnosis:
- mainly prenatal
- severe RDs in first few hours
- scaphoid abdomen
- inflated chest
- unequal breath sound +intestinal sounds
- x-ray shows gas of stomach and intestine in chest + shift of
heart + small lung
Treatment:
Surgery (emergency) >> ( Pre operative) : - Good oxygenation
- intubation
- Metabolic support
- NG( Ryle)
- Arterial catheter for
ABG
3 :
1- Hypoglycemia : mainly in macrosomia
= RBS 40 mg\dl , Onset 1 2 hr of age , Cause : neonatal
hyperinsulinemia hypoglycemia
Management :
C\P : lethargy , poor feeding , apnea , jitterness
Measure blood glucose ( RBS ) at :
- Once \ hr in the 1st 4 hrs
- Once \ 6 hr till end of the 1st day
- Once \ 12 hr till end of the 2nd day
88
So : at 1,2,3,4,6,12,24,36,48
hypoglycemia : manage
If
2- Respiratory distress :
Cause : delayed lung maturity caused by hyperinsulinemia that blocks cortisol
induction of the lung maturity
Others : cardiac & pulmonary anomalies , polycythemia , pneumothorax ,
pneumonia , C.S. delivery( TTN ) , diaphragmatic hernia.
Management : CXR , ABG , ECG , ECHO , CBC , Blood cultures
If RD : manage
3- Hypocalcaemia : in 50 % of cases
Cause : controverse : delayed in parathromone or Vit D antagonize by cortisol
, asphyxia , prematurity
Occure in the 1st 24 27 hr , Ca 7 mg \dl ( total )
Invest. : total serum Ca / ionized Ca
Management : prophylactic : Ca from 1st day ,
curative : C/P & TTT
12345678-
3 :
Resuscitation
Search for any congenital anomalies
Vital data specially RR , HR , BP , Perfusion
Trauma : brachial plexus , fracture clavicle or limbs
Small for G.A. : suspect mother with renal or cardiac diseases , prematurity
Reflexes
Invest. for CBC , HB , HCT , CXR , Ca , Bilirubin , ABG
Feeding :
Other problems :
1- Polycythemia : partial exchange transfusion ??
2- Jaundice :
Cause :
- indirect : polycythemia more distruction , prematurity
- direct : inspisated bile $ ( Treatment : as
jaundice , early obstruction , early lab. , early phototherapy )
3- Congenital anomalies : see with bad contol
as cardiac , CNS & Vertebra , skeletal , renal
4- Macrosomia 4 kg or 90 %
Cause : insulin & glucose
C\P : hypoglycemia & trauma
5- Myocardial dysfunction :
Cause : ventricular septal hypertrophy ( idiopathic )
C\P : CHF , poor C.O.P. , Cardiomegaly
89
CXR : cardiomegaly
Echo is diagnostic
Resolve in 4 months & symptoms at 2 weeks
Inotropics contraindicated unless myocardial dysfunction by Echo
N.B. HOCM TTT : Inderal ,NOT lazix , capoten, lanoxine
6- Renal vein thrombosis :
C\P : hematuria , flank mass , hypertension , embolic phenomena + +
Inv. : U\S
,
TTT : conserve
7- Poor feeding
8- Small left colon syndrome :
Generalized abd. Distension due to inability to pass meconium
TTT : enema or glycerin supp. + feed + IV fluid
9- Hepatosplenomegaly
Post maturity :
- Problems :
1- RD
2- Hypoglycemia
3- Hypocalcemia
4- Polycythemia
5- Birth trauma , very large size baby
Jitteriness DD :
1- Hypocalcaemia : exclude 1st ( double ca )
2- Hypoglycemia : exclude 2nd
3- Renal impairment : ask renal inv.
4- Hyperbilirubinemia : esp. direct type
Jitteriness , Convulsions Jitteriness -:
Prematurity ( )
-
Preterm
-CPAP or Vent
For hypothermia -Minimal handling
- Glucose 10% 2 days
-Ca from
1st day
-Unacin, Amikin, Fortum
-
92
-Konakion
-Dopamin, Dobutamine
-Plasma for anemia
-Moitor Bl.Pr >>shock
- Urination
IUGR <2500 gm
Problems:
1-RD & asphyxia
2-Hypoglycemia
3- Congenital Malformation
4- Sepsis
5- Hypocalcemia
6-Hypothermia
7- Polycythemia >> increase fluids
8-PPHN (Persistant pulmonary HTN of Newborn)
Due to chronic intrauterine hypoxia >> thickening of smooth
ms of small pulmonary arteries.
So don't forget,,
1-O2
2-Aminophylline>>for apnea
3- Ca Dobule
4- Zantac for stress ulcer
5-Abs
93
Jaundice ( )
1-Bilirubin::
-Formed from hemoglobin due to red cell breakdown
-2 forms> Direct(conjugated) ,Indirect(un conjugated)
-Bounded to albumin (Indirect) conjugated in liver (direct) &
excreted in stool
-measured by mg/dl or M mol/l & (mg/dl X 17.1= m mol/l)
-indirect is orange yellow & direct is greenish yellow.
-in dark babies >>press your finger on skin & observe
4- Causes of hyperbilirubinemia::
a-Physiological jaundice
b-hemolytic states: Indirect+ anemia
-Isoimmune; Rh , ABO
-Congenital hemolytic anemia: G6PD, Thalassemia,
spherocytosis
-Hematoma, excess brusies, polycythemia
c-Mixed hemolytic &hepatotoxic states: increase direct &
indirect bilirubin.
As bacterial infection, TORCH, Drugs, vit K deficiency
d-Hepatocellular damage: Both direct(>20% of Total) +indirect
, like biliary
atresia , galactosemia, hepatitis
e-Uncertain mechanism: breast milk jaundice, racial
Lab
Cause
TTT
1-jaundice +
normal
appearance (+-)
PT
-ve combs,
normal HCT,
retics ,film
-immature
liver
Good
hydration
( + -)photo
-increase direct
+ indirect , -ve
combs, low HCT,
+ve sepsis work
-decrease
conjugation
hemolysis:R
h or ABO
-antibodies&
anemia for
longer
-sepsis
-Abs
-no photo if
high direct
95
up
4-J + Plerthoric +
SGA or one of
twins
-as before
-partial
exchange
-congenital
intrauterine
infection
Medical ttt of
cause
6- J + Abd
distension +
vomiting + no
stool
-increase
indirect, others
> normal
GIT
obstruction
-hydration +
NPO + NG
suction + X-ray
7- J+ multiple
brusies + difficult
labor + head
swelling
-ve combs,
others :normal
Cephalohematoma
As before
8- J + long time +
breast fed + all
normal
All normal
Breast milk
jaundice
Follow up,
stop breast
fed 2 days,
artificial milk
6- Types in details::
1-Physiological jaundice:
-Very common 2/3
-Doesn't appear in 1st 24 h
PT
96
Appearance 2 , 3
Up to 12
Duration 7 10
Appearance 3 , 4
14
14
2- Prolonged jaundice :
Def. : apparent jaundice for 10 days after birth in full term baby & for 2 weeks
in preterm baby .
Cause : breast milk jaundice is the commonest & non specific hepatitis in
VLBW
Other causes : sepsis ( UTI ) hypothyroidism inspissated bile syndrome
( very high unconjugated bilirubin followed by conj. ) delayed passage of
stool pyloric stenosis obstructed jaundice syndrome .
3- Breast milk jaundice :
Usually at day 4 , bilirubin fall but here it continues to rise up to 20 mg\dl at 10
14 day of age .
If breast feeding is continued , the level stay elevated then fall slowly .
If breast feeding stopped , bilirubin level fall rapidly within 48 hr & when
breast feeding resumed the level rises again but not the previous high level .
Recurrence is common in next pregnancy 70 %
Can lead to kernicterus .
Unknown cause but some say pregnandiol in milk suppress conjugated enzyme
4- Breast feeding jaundice :
Infants who are breast feed have higher bilirubin level compared to formula
feed infants .
Cause : intake of milk enterohepatic circulation
Cholostrum constipation enterohepatic circulation
97
Cells of basal ganglia in the midbrain are metabolic active & receive the largest
blood flow .
It is risk with immaturity , rapidly raising bilirubin , low albumin , hypoxia ,
acidosis , sepsis , hypoglycemia .
C\P : initially , infant has non sp. Signs of like poor suck , lethargy of
hypotonia + high jaundice & within hours , it progresses to fever , hypertonia
of extensor ms. Groups leading to opisthotones (trunk & neck arching) ,also
convulsions may be +ve
If left un treated : fetal or sever brain damage can occur
Preterm infant may develop apnea with tone .
Immediate exchange transfusion better proceeded by albumin transfusion ,
should be done .
11- Indirect hyperbilirubinemia ( cong. ) :
Def. : if direct bilirubin > 20 % of total or > 2 mg\dl , A persistence or
elevated direct bilirubin is always pathological & must be evaluated & a value
> 5 mg\dl is consider sever case .
Causes :
Idiopathic neonatal hepatitis , the most common (by exclusion).
Biliry atresia : 2nd common cause , need surgery otherwise LCF
TPN ( unknown mechanism ) if > 2 w esp. in preterm infant .
Sepsis or UTI
Intrauterine infections ( TORCH )
Inspissated bile syndrome
Choledocal cyst ,
antitrypsin
Galactosemia
Inv. : liver functions CBC urine & blood culture reties Coombs test
TORCH screen U\S for liver & biliary tract liver biopsy radionuclide
scan .
Clinical application
Jaundice
a) History :
- Prenatal , natal , postnatal history
- feeding pattern family history of hemolysis
- previous jaundiced baby .
- Rh status
- Time of start
99
b) Examination :
- Color : indirect \ direct
- Distribution :
6
9
12
15
15
- Look of signs of infections
- Look for area of accumulated blood as cephalohematoma or bruises .
- Liver & spleen size ( if hemolysis )
- Pallor , suckling , feeding ability
c) Investigation :
Start TSB , DSB , reties
- Severity bilirubin
Indirect hemolysis reties
: reties
- ABO groups for infant & mother
( usual In the 1st 3 days ,esp. in the 1st day 3 )
- ABO incompatibility B or A O
Rh
- Direct bilirubin
inspissated bile syndrome
CBC for anemia
CRP for infections esp. UTI
N.B.
* Jaundice > 14 days must be investigated At least by TSB - DSB
Hct
thyroid function urine culture .
* It is not physiologic if appear in the 1st 24 hr or by 0.5 mg\dl\hr
or > 2 in 4 hr or
evidence of hemolysis abd. examination or direct > 20 % or
persistence > 3 weeks .
* Infant with breast feeding jaundice are liable for hemorrhagic
diseases , So be
100
Age (hr)
Photo ( TSB\mg\dl )
Exchange transfusion
1st
Up to 24
10 - 12
20
2nd
25-48
12 15
20 25
3rd
49-72
15 18
25 30
4th
>73
18 20
25 30
Photo ( TSB\mg\dl )
Exchange transfusion
Up to 24
7 - 10
18
25-48
10 12
20
49-72
12 15
20
>73
12 15
20
photo
exchange
Sick baby
photo
Exchange
101
Up to 1 kg
57
10
46
8 - 10
1 : 1.5
7 - 10
10 15
6-8
10 12
1.5 : 2
10
17
8 10
15
> 2 kg
10 12
18
10
17
Phototherapy
Types of phototherapy :
1- Conventional
2- Prophylactic : in VLBW , cephalohematoma , polycythemia .
3- Intensive photo :
102
Bli-bild device
Advan :- more exposure ( increase surface area )
Disadvantage :- hypothermia >> poor suckling
Problems :
1- transit time diarrhea .
103
2- Dehydration .
3- Hyperthermia .
4- Rash examine regularly .
5- Eye problems if exposed so turn off
6- Bronze baby syndrome if used in direct bilirubin .
7- Genital problems if exposed .
8- Anxiety to parents .
:
1- Feeding ( frequency ) +
2- Abd. Distension
104
3- Suckling power
4- Hypoactivity >> sleep with no cry
:
- TSB , DSB
- CBC
It is critical to recognize neonatal seizures & known their etiology & TTT them
urgently .
Complications :
1- The cause is usually serious
2- O2 consumption , So hypoxia & brain injury .
3- Interfere with supportive measurement as ventilation & elimination .
Causes :
1- HIE : the single most common cause ( see later )
2- IChge
3- CNS infection : see later
4- Metabolic as :
- Hypoglycemia
- Hypocalcaemia
- Hypothermia
- Vit B6 ( cortigen B6 )
Exclusion
Convulsion resistance to TTT & TTT by 0.5 cm IM cortigen B6
5- Kernicterus
6- Polycythemia
7- Developmental
8- Drug withdrawal
9- Familial
10- Others like : Fifth day Fits , hydrocephalus
N.B.
it is important to diff. between jitteriness & convulsion ( for
jitteriness see IDM ): Limb .... Jitteriness
105
Convulsion
Management :
Emergent measures
1- check ETT + increase FIO2 + glucose
measurement
+give ca
1- TTT of cause
So inv. ( Ca total ionized , glucose , bilirubin , CRP )
2- Supportive measurement ( ABC ) : O2 , suction , position(see later)
3- Anticonvulsant drug
Significant convulsion
saturation Significant
Drugs :
( )
1- give somonileta 15 mg/kg as (L) & wait 0.5 hour if no
Response give another loading & wait 0.5 hour
2- If no R give epanutin then
1- Phenobarbitol ( PB ) =
- Is the 1st line drug & it is sedative
- It is give loading dose of 15 mg \ kg \dose over 10 min.
+ careful monitoring of respiration .
- If initial dose is effective wait for 0.5 hr , the additional dose of
5 mg \kg \ dose can be given every 5 min. till seizures or a total dose
of 40 mg \ kg is reached .
- Then maintenance 5 mg\kg\day is given &started 12 hr after loading dose
2-phenytoin = epanutin
106
Diagnosis :
The organism may be streptococci ( GBS ) E.coli H.influanza .
C\P :
1- Bulging fontanel ( anterior )
2- Arching back
3- Convulsions
4- Hypo or hyperthermia
5- Neck rigidity
Investigations :
107
CBC , CRP
LP ( lumbar puncher ) for CSF
Treatment :
1- Drugs
100.000 200.000 : 300.000
2- +
3- May +
4- May + antiviral ( tab = 400 mg )
0.5 tab \ 5cm glucose 5 % \ 8 hr =
Dose = 10 mg \ kg \ dose
5- +
6- TTT of convulsions anticonvulsant drug
7- Supportive measurement
A- Indications :
1_ Urgent administration of resuscitation drugs or adrenline .
2 Hypertonic solution 12.5 .
3 Giving blood and blood products .
4 Measure CVP .
5 Exchange transfusion .
6 In no cannula can be done
B- Contraindications :
1 Omphalitis
2 Omphalocele
3 NEC
4 Peritoritis
108
C- Tools :
1 dressing - betadine alcohol
2 blade forceps syringe silk suture 3/ 0
3 Flush solution ( Normal.saline + 1 unit . heparin )
4 unbilical catheter
a - 3.5 for ELBW
D- Steralization (Clean ,
c - 8 for >
3.5 kg
Tie , Cut )
1 Betadine ( 3 times )
2 alcohol
( one time )
109
K- confirm >>
- superficial
- continous flow and not pulsating
- IVC liver sinusoids interrupted flow
x_ray ( )
L- suture by silk >> by purse string suture
M- fix catheter
N-nursing care & frequent cleaning of catheter
O-removal (7-14) days without complications / or reached 15cm
Complications
A. Air embolism
B. thrombosis
C. malposition>>>> If inserted in
1. right atrium or SVC >>> pericardial effusion
2.
arrhythmia
5.
leakage
1.maturity
4.malcare
2.technique
3.days
5.heparin
1. clots
2.
3. saline
4.
5.
6. ( silk Weak )
-: resistance
NB :- x-ray findings
1. if to right >> hepatic
2.above >>>upper border of liver
3.run in middle of vertebral column till T9 at least
Sizes
1. < 1 kg >>>>2.5
2. (1-2)kg >>>>3
(from 28 wk to 34 wk)
>>>>4
(>38 wk)
N.B
1. problems with use of smaller tubes than need leads to leakage of air
2.problems with use of larger tubes than need leads to laryngeal odema and
injury
111
Indications
1.IMV
2.tracheal suction
3.In CPR
Procedure
1.position : slight extension
2.use laryngoscope (check light)
3.when you insert , you will find darkness , so pull it backwards till you find
epiglottis
4.push it forward till you find vocal cords (moving)
5.insert the tube but avoid forced insertion
Fixation
1.if oral >>> 6 cm +wt
2.if nasal (not used) >>> 7 cm +wt
N.B
You should use ambo first to improve saturation and also for suction
Confirmation of position
1.you can see water vapour with breath
2.auscultation: by ambo better on rt axilla and left axilla and both sides
of chest and if air entry
is heard equally or not (you may find right side more , so pull the tube
above and hear again)
112
Complication
1.obstructed ETT by secretions or kinking:will find cyanosis , desaturation
and by
auscultation , you will find diminished Sounds and decreased chest
inflation ,so change
the tube or make suction
2.infection
3.injury to vocal cords and esophageus
4.pneumothorax if there is increase in PV or in case of right side intubation
5.bradycardia due to hypoxia or vagal stimulation
6.hypoxia
Hyperglycemia
-Complication:
1-if blood glucose >a80 mg / dl >>>osmotic diuresis ,
dehydration ,acidosis
2-if serum osmolality >300mosm /L>>> cerebral He
113
N.B:
-serum osmolality=2 (Na by mmol/L+K by m mol/L)+urea by m mol
L+glucose by mmol/L
-Urea (mg/ dl)/ 6 =m mol/L
-glucose(mg/dl) / 18 ==m mol /L
- Causes:
1-iatrogenic ( TPN )
2-prematurity & ELBW ( due to decreased glucose utilization )
3-sepsis: stress asphyxia intracranial Hge
4-drug as steroid , theophyllin
5-neonatal DM
6-ingestion of hyperosmolar formula
- Diagnosis:
*monitoring for high risk
*N.B: don't take sample from vein where i.v line is present with
glucose infusion
- TTT:
A-Prevention :-
- :
1:1
4:1
D 10 >>>100
ml>>>>10 gm
D25>>>>100ml>>>>>25gm
5- measure concentration of glucose if >12.5>>>>>>>need
central line
Hypoglycemia
-causes:
1- low glucose stores : premature , IUGR , asphyxia , hypothermia ,
meconium
aspiration ,$
2- IDM
3-sepsis
4- others : polycythemia , exchange transfusion ,drugs as
propranolol ,
oral hypoglycemic
-C/P:
1- of cause as sepsis
2- absent c/p
3- non sp : tremors , jitteriness , exaggerated Moro reflex , poor
feeding , irregular respiration , apnea , seizures , cyanosis ,
hypothermia
- TTT:
-most important >>good monitoring in high risk as IDM plan
-start feeding as early as possible
TTT plan
A- Asymptomatic :
glucose < 25 mg / dl
glucose 25-40
117
Give iv D 10%
-loading : 2 ml / kg at rate of 1 ml /
min then infusion(maintenance) at 5
ml / kg / hr
( 4:8 mg /kg / min )
+ Begin feeding + Monitor every
30 min
B-symptomatic :
without convulsion :
with convulsion:
Glucose
- RBS > 40 or with no symptoms >> give 2cm/kg/dose of
G
10% or 5 %
- RBS < 40 with symptoms especially convulsions >>> give
4cm/kg/dose
118
Hypocalcemia
Causes :
1- early onset ( 1st 3 days ) normal , preterm , IDM , asphyxia
2- late onset (end of week ) :- hypoparathyroidism , vit D deficiency
, RF ,
anticonvulsant in mother
3- others : alkalosis , bicarbonate , exchange transfusion , lasix ,
photo , albumin
rapidly
Hypercalcemia (rare)
TTT:-
-ttt of cause
-adequate fluid
-lasix
A - hypovolemic :
B - Distributive :
C - cardiogenic :
-placental
hge(placenta previa)
-sepsis
-drug as muscle
relaxant
-myocardial
dysfunction as
120
-fetomaternal hge
-twin to twin
transfusion
-adrenocortical
insufficiency
asphyxia &
myopathy
-outflow obstruction
as coartication of
aorta ,
-arrythemia
-inflow obstruction
e.g pneumothorax
-TAPVR
C/P:
TTT:
- reconfirm the reading & c/p
-exclude : PAD , hypovolemia , pneumothorax , sepsis ,
adrenocortical insufficiency
in preterm
- high mean airway pressure on IMV ( cause vc of vessels
>>>decrease C.O.P )
CVP measurement 5-8 mmhg-
Lines :
1-volume replacement : albumin 10 ml/kg of 5% albumin over 20-30
min or
shock therapy
2-inotropes : dopamine & dobutamine & adrenaline .05 mg / kg /
min up to
121
1 mg /kg /min
3-indomethacin:.1 mg/kg if PDA
4- hydrocortisone : 2.5 mg/kg in 2 doses 4 hrs apart if preterm with
adrenocortical insufficiency
5- sepsis :AB
Hypertension
C/p:
tachypnea , lethargy , abnormal muscle tone , impaired renal
function , congestive HF, hematruia , proteinuria , edema ,
seizures
Causes :
-drugs : dopamine ,dexamethazone
-stress : pain , cold
-renal :renal artery stenosis , obstructive uropathy
-coarcitation of aorta
-endocrinal : Renin-angiotensin path
-increased intracranial pressure : inrta ventricular hge , cerebral
edema
122
TTT:
1-drugs : - Lasix
HYPERTHERMIA
Causes:
-direct overheating : photo , radiant warmer
-overheated environment : increase incubator temperature ,
incubator in sun light , exess clothes , warm room
-infection : but more hypothermia
-dehydration fever >>>decreased fluid intake
-drug effect: PG E
Complications:
-increased metabolic rate & o2 consumption >>> increased RR,
HR , fluid loss , irritability , apnea , periodic breathing ,
dehydration , acidosis , brain damage
123
TTT:
1- determine source :endogenous ( infection ) or exogenous
2-turn off any heats source & remove excess clothes
3-feeding or drink water (thirst usually )
4- sepsis work out
5-significant temp elevation
-tepid water sponge bath
-paracetamol 5-10 mg / kg / dose / 4 hrs oral or rectal
Hypotheremia
-measured : best
by axilla
Causes :
-heat loss to environment by 4 methods:
1-conduction: contact with cold object
2-convection : cold air circulating around body
3- evaporation : evaporation of liquid from wet warm
4- radiation :baby near but not in contact with cold object
-sepsis: lead to hypo or hyper
124
Complication :
1- hypoglycemia : due to increased metabolic rate to increased
heat
2-acidosis : due to conversion of brown fat to heat & fatty acid
& lactic acid ( by glucose )
3-hypoxia :consumed o2 in metabolism + acidosis cause V.C of
pulmonary vessels
4-others : apathy , feeding problems , paralytic ileus , brady , IC
hge , bleeding
Risk factors :
1-preterm: low brown fat , increased surface area
2-SGA
3-sick baby
TTT:
-warm slowly as rapid warming may lead to apnea ,
hypotension
- Rewarm at 1 c/ hr
.
1-take a brief history ( Name ,age , sibling , type of labour.. CS/VD
, FT/PT , maternal DM, HTN ,PROM , state at birth , cause of
presentation , times in incubator )
125
2- Questions to mother ?
- ) ( -:
-:activity -
cough , fever( infection ) -
- examination a-auscultate chest
b-colors >>>pallor , jaundice ( Lab. Tests )
c- Heart , abdomen
d-umblicus care >> If pus >> anaflex powder (AB) +
regular cleaning
by alcohol
Poor perfusion
Tachycardia
-Normal HR :120-160 may reach 70-90 during sleep & 170-190
during cry
-transient tachy or arrhythmia or brady <15 s are begun
-see associated : tachypnea, poor perfusion, lethargy,
-causes:
1-Benign :post delivery , cold , heat, painful stimuli, drugs as
(atropine- epinephrine, aminophylline)
2-Pathology: fever, shock, hypoxia, anemia, sepsis, PDA, CHF ,
Hyperthyroidism
127
2- vomiting
3micturation
4-gavage feeding
Pathophysology:
Hypoxia
Apnea
convulsion
IC Hge
Others causes:
airway obstruction
air leak
(pneumothorax)
CHF
severe acidosis
1- hyperkalamia
severe hypothermia
2-cardiac arrhythmia
diaphragmatic hernia
4-hypothyrodism
3-
5-hydrocephalus
Treatment
1- prevent the causative drug
2- treatment of the cause
3- in severe hypotension or arrest CPR
4- Atropine + Adrenaline / epinephrine
128
DD of tense fontanels
1-hydrocephalus: * measure head circumference routinely
* Ask CT
2- ICH
2- CNS infection
4- brain edema : need mannitol cortisone
Risk factors
1-prematurity
2-sepsis
3-hypoxia
4-overfeeding
5ischemia
Diagnosis : by a triad of
1-distension
2-metabolic acidosis (by ABG)
3thrombocytopenia (by CBC with differentials )
TTT:
14-7
strong antibiotic ( Combination of (Vanco , Meronam , Flagyl ,
Diflucan
130
Neonatal edema
- Common causes :
1234-
Sepsis
Prematurity
Delay or decrease dose of aminovein
Renal failure : either
1- prerenal >>> hypotension
2- renal problem
3- post renal obstruction
How to manage :
1- nephrotoxic
2- ask u
rea ,creat. + Na , K
3-press on urinary bladder >> why
post renal obstruction
( renal, pre renal, atonic bladder) in
H.I.E cases >>
4-give challenge test>>> shock therapy +lasix ( if urine come , the
cause is prerenal )
5-measure blood pressure
6-give plasma / 12 hr >> to increase osmolarity
edema pre renal fluid tissue
masked hypovolemia fluids
131
Down syndrome
* How to suspect? The most important signs are
1-low set ears >>
medial canthus lateral canthus
low set ears
2-wide spaced medial canthus + epicanthus
3- simian crease.
4-wide space between 1st & 2nd toe.
Shift 1
132
-baby who give residual digested >> give it to him & see how
much( < or> 10%) & mange as before
-Brownish secretions from stomach before starting feeding isn't
contraindication for feeding
- )
( 6/2
-anemia>> hemic murmur
- ... ( 6)
- vent x-ray areation, pneumonia
ABG
- ETT ... Ryle
- << vent
RR setting A/C CPAP
NASAL
- : PT Vent
CBC, CRP ecchymosis X-ray
- Double
- Post vent Anerobes
- hypoactive sepsis Sedation
4- solutions
Shift 2
-1
10 :-Anemia 2-RD
Shift 3
Shift 4
Preterm on IMV -1
Fi O2 40% PEEP 3
inspir/respir 1 : 3
time 0.36
rate 40:35
5- ventillator
6- 10 acidosis HCO3
a\c sedation
7-
8- pulm.cort
9- pulm cort ( Beclomethazone ) :- inhalation long acting steriod
neonate chest infection
atrovent
10- Hepatomegally is present with UVC
2sepsis
Treatment:
1- 1st do urea and creatinine
2- ask for plasma \ 12 hours to increase osmolarity
136
circulation 5
6
2- empty bladder
- bladder
challenge test
renal failure ( pre renal or renal
causes)
- Atonic bladder
- shock therapy
- hyperkalamia
1 24 )) \
15- Treatment of BPD is steroid , lasix , amionphyline
16- In x-ray if you find apical patch it should not be pneumonia and
it may be collapse
137
As pneumonia need:
shift of
mediastinum.
brain oedema
Shift 5
138