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Unit 2.1 Neo/pediatric case studies

Unit 2.1 Neo/pediatric case studies. Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP. Case study. You are called to L & D for a stat C-section for “late decells.” What is the significance of this?. The fetal heart rate is decreasing to bradycardia and not coming back up to baseline.

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Unit 2.1 Neo/pediatric case studies

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  1. Unit 2.1 Neo/pediatriccase studies Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

  2. Case study • You are called to L & D for a stat C-section for “late decells.” What is the significance of this?

  3. The fetal heart rate is decreasing to bradycardia and not coming back up to baseline.

  4. What else do you need to know?

  5. answer • 1. gestation of baby • 2. mother’s prior birth history • 3. history of this pregnancy • 4. history of this labor • L/S ratio or phospha-tidyl-gycerol levels • Shake test of aminiotic fluid and ethonol

  6. This is 28 weeks gestation. Mom is 25 year old, G2 P2. The labor was complicated by PROM. • You are concerned because:

  7. answer • The baby will be premature & at risk for IRDS type I • The baby is at risk for infection due to the PROM

  8. The baby is born. At 1 minute of life, you see that the HR is 88 bpm, the baby is apnic, blue and flaccid. He is unresponsive to tactile stimulation • You respond by:

  9. answer • Mask bag with 100% 02 at a respiratory rate of 40-60 bpm

  10. What is the APGAR at 1 minute?

  11. Answer: • 1 at 1 minute

  12. At 3 minutes of life with bagging, the baby starts to pink up, but fails to attempt to breath. At Fi02 100% by mask bagging, the Sp02 rises from 73% to 92% • You recommend what?

  13. answer • Intubate and ventilate the infant • Instillation of artificial surfactant to reduce the severity of his IRDS type I

  14. Baby is AGA 26 week preemie by exam. He is intubated with an # 2.5 endotracheal tube and it is taped at the 10 how do you assess this patient now?

  15. answer • Listen to bilateral breath sound: they are equal in the right and left at the axillary but you hear crackles in the upper lobes, and diminished breath sounds in the basal areas. • Repeat APGARs in 5 minutes

  16. You are bagging at a PIP of 13 cmH20, and an Fi02 100% and rate of 45 bpm. The Sp02 is 93%. • What do you suggest?

  17. answer • Get an arterial blood gas: • The pH is 7.34 the PC02 is 35 and the Pa02 is 65 torr.

  18. Looking at these gases, what do you want to do?

  19. answer • Get a pressure ventilator set up on the following settings: • IMV 45 • PIP 13 • PEEP 5 • Fi02 100% • Ti .30 to .5 seconds [closer to .3 if VSBW infant] • Flow rate 8- 10 lpm • And repeat the gas on these settings

  20. That baby is put onto these settings and you see good chest movement and you see the Sp02 on the right hand is 95% • What do you want to do now?

  21. Answer • Get x-ray: • you see low volume lung with diffuse alveolar infiltrates and air bronchogram

  22. An umbilical artery catheter is placed and in one hour, you get an ABG on the current settings. • pH 7.33 • PaC02 45 • Pa02 48 torr • Sa02 88% [Sp02 is 88%] • What has happened & what do you suggest?

  23. answer • Increase the Vt by increasing the PIP from 13 to 14. • Increase the PEEP from 5 to 6 • Repeat ABG

  24. What is this baby’s most likely diagnosis?

  25. answer • HMD [IRDS type I] but we cannot r/o intrauterine pneumonia.

  26. Case study # 2 • You are called to L & D for a SGA baby who is 32 weeks by date. Mom is G6 P3 A3 and she is 38 years old. She has gestational diabetes • The baby is delivered 5 hours after labor started and membranes broke. • It is SVVD • What do you expect?

  27. answer • Mom has a bad track record of infant deaths. • Baby is premature • Baby is not at risk for infection • Even if baby wasn’t premature, he could have immature lungs

  28. What is a problem with sucessful diagnosis of IRDS I with a infant of a diabetic mom?

  29. answer • The L/S ratio may not be accurate, • You need to look at the phospha-tidyl-gycerol for lung maturity in infant of diabetic mom

  30. At birth, baby is flaccid, apnic with heart rate 95 bpm, blue centrally and peripherally. • What is the APGAR? • What is your intervention?

  31. answer • APGAR at 1 minute is 1. • Start bagging with 100% at a rate of 40-60 bpm. • Look at Sp02 • Listen to breath sounds with bagging

  32. In 3 minutes, baby is intubated and bagged with 100% Fi02. • Bilateral breath sounds: equal and bilateral. Diminished basal breath sounds, crackles in upper lobes. • Sp02 is 88% • What do you want to do?

  33. answer • Get an ABG • Note the PIP you are bagging with • Place patient on PEEP • Repeat Sp02 in a few minutes

  34. If you did an L/ S ratio on this kid what results would you expect?

  35. 1. Infant who have L/S ratio of more than 2:1 have mature lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  36. Case study # 3 • Mom is 45 year old WF G3 P3. gestation is 38 weeks. • Stat C-section for late decells • Membranes ruptured at 1300 and the baby wasn’t delivered till 1500 the next day. • Mom is febrile with respiratory infection • What are the maternal risks, what are we worried about ?

  37. answer • 38 weeker infant is low risk for IRDS • Febrile and PROM puts baby at risk for intrauterine pneumonia and sepsis. • Late decells puts baby at risk for fetal distress. • What do you want to monitor?

  38. answer • APGAR’s and Silverman’s • Tracheal aspirate for culture and sensitivity • Spinal tap and blood cultures for sepsis • Breath sounds and pulse oximetry

  39. Case study # 4 • Baby is a 39 weeker who is delivered by elective C-section on Feb 14 because the parents want a ‘valentine baby’ • How do you assess this infant?

  40. answer • Get APGAR at 1 minute • Get Silverman Score • Listen to breath sounds • Get Sp02 • Get more history on the mom

  41. Baby has an APGAR of 8 [lost points for color] • Baby’s Sp02 is 75% then rises to 85% within a few minutes with 30% 02 blow by • Silverman is 6 • Breath sounds show diffuse crackles in the bases. • Mom is 28 year-old WF G1 P0

  42. What else do you want to assess?

  43. answer • VS: RR 65 bpm, HR 135 bpm • X-Ray • Cardiomegally, and diffuse alveolar infiltrates and increased hilar markings. Plural effusion in the RLL • Blood gas: • pH 7. 34 • PC02 33 • P02 53 torr • Fi02 30% by hood

  44. What do you want to do?

  45. answer • Increase the Fi02 from 30% to 35% and recheck the pulse ox. Continue to raise the Fi02 until the Sp02 is above 90% • The C02 is ok, but repeat the ABG if the increased Fi02 doesn’t help the Sp02. • If the Fi02 rises above 40% repeat a Blood gas to assess the need for CPAP

  46. What is a likely diagnosis with this infant?

  47. answer • If he gets better in the next 6 hours, we can assume he has TTN • If he gets worse , he might have mild HMD • Consider cardiology consult if the cardiomegally doesn’t resolve in a few hours

  48. Case study # 5 • L & D RCP calls you. She is doing CPR on a post-term infant who has APGARs of 1 at 1 & 4 at 5. They did chest compressions for 8 minutes before the child responded. • What else do you need to know about this patient?

  49. answer • What is the mom’s history? • 18 year old G1 P0 • What is the history of the pregnancy • No known problems • What is the history of the delivery? • Spontaneous breech birth, No PROM, but late decells in the last few minutes of labor • Greenish black colored amniotic fluid

  50. What do you hope the RCP did in L & D?

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