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“Critical Neonate”

“Critical Neonate”. Pediatrics N 1 & neonatology department Professor Olena Riga Professor Margaryta Gonchar. WHO , Borntoosoon,20 12. Degrees of prematurity . Low birth weight ( LBW ) – BW < 2500 g Very low birth weight ( VLBW ) – BW < 1500 g

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“Critical Neonate”

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  1. “Critical Neonate” Pediatrics N 1 & neonatology department Professor Olena Riga Professor Margaryta Gonchar

  2. WHO, Borntoosoon,2012

  3. Degrees of prematurity  • Low birth weight (LBW) – BW < 2500g • Very low birth weight (VLBW) – BW < 1500 g • Extremely low birth weight (ELBW) – BW < 1000g • Late preterm infants – (LPT) GA 34 - 36 wk’s and 6 days • Very premature infants (VPT) – GA < 32 wk’s • Extremely premature infants (EPT) – GA < 25 wk’s

  4. Relation of Perinatal Mortality Rate to Birth Weight

  5. NEONATAL DEATH SURVEY • Every hour around 450 babies die before the age of four weeks. • Around 60-80% of neonatal deaths arise in low-birth weight babies

  6. Infant Mortality is a Personal Tragedy

  7. Neonatal problems • Asphyxia and Neonatal Encephalopathy • Prematurity • Respiratory Distress syndrome • Sepsis • Shock

  8. Asphyxia of the newborn

  9. Gas exchange

  10. Heart rate, breath movements and blood pressure in fetus during primary and secondary apnea

  11. Apgar Score of the Newborn • SIGNSCORE012 • Heart rateAbsent<100 beats/min>100 Respiratory • effortAbsentWeak,irregularStrongcry • Muscle tone Flaccid Some flexion Well • Reflex irritability (response to catheter in nostril) No Grimace Cough or sneeze • Skin colour Blue, pale extremities blue pink

  12. CRITERIAS OF SEVERE ASPHYXIA: • Severe metabolic or mix acidosis pH ≤ 7.00 in arterial blood of umbilical vessels • Assessment by Apgar is 0-3 during more than 5 minutes • Neurological symptoms such as general hypotonic, lethargy, coma, seizures • Damage of vital organs (lungs, heart and other) in fetus or newborn

  13. Acute complications associated with Asphyxia • hypotension • hypoxic encephalopathy • seizures • persistent pulmonary hypertension • hypoxic cardiomyopathy • ileum and necrotizing enterocolitis • acute tubular necrosis • adrenal hemorrhage and necrosis • hypoglycemia • polycytemia • disseminated intravascular coagulation

  14. Brain Edema

  15. Periventricular leukomalacia

  16. DIAGNOSIS • Clinical symptoms • Metabolic derangement • Renal and/or cardiac failure • Assessment of the brain: • a.. EEG EEG is useful particulary in the asphyxiated term newborn.

  17. DIAGNOSIS • Serial recordings are almost necessary. • Low voltage. Burst-suppression patterns or electrical inactivity are associated with bad prognosis. • Rapid resolution of EEG abnormalities and/or normal interictal EEG are associated with a good prognosis. • b. Ultras onography: Ultrasound can be useful in premature newbomsbut is of more limited value in the term newborn. • c. Computed tomography: CT is of major value both acutely during theneonatal period and later in childhood. The optimal timing of CT scanning isbetween 2 and 4 days.

  18. DIAGNOSIS • I. Intrauterine assessment • A. Ultrasound and Doppler technique: • Ultrasound: to measure the growth of the fetus. For this reason it is important have a reliable gestational age. Early during pregnancy an ultrasound will be done to date the fetus. This method safer than common clinical methods. The growth retarded fetus is in a great risk of developing asphyxia. • Doppler techniques: to measure the blood flow in the umbilical vessels or aorta. A low flow or decreasing flow indicates a fetus in risk of asphyxia.

  19. DIAGNOSIS • B.Electrofysiological: • Severe pathological fetus heart rate will lead to cessation of the delivery with Caesarean section. • Fetal heart rate: Episodes of bradycardia can be dangerous and lead to brain damage. The problem is to do this type of measurement during long periods and on every pregnant woman

  20. DIAGNOSIS • II. Extrauterine assessment • C.Biochemical • - C blood sample drawn from the umbilical artery is an ideal way to evaluate whether an intrapartum asphyxia exist or not. Low pH (< 7, 00) indicates the intrapartum asphyxia. • PC02 and P02 will also be deranged as you have a diminished gas exchange. The low pH is the result of an increased level of H+ and lactate.

  21. EEG

  22. ABC resuscitation • A- Airways (maintenance of passable ness of airway) • B- breathing (stimulation of breathing) • C- circulation (to support of circulation) • D-drug

  23. ABC resuscitation • Step A- immediately after delivery the infant’s head should be placed in a neutral or slightly extended position • Rolled towel under the shoulders

  24. Step A- immediately after delivery the infant’s head should be placed in a neutral or slightly extended position

  25. And airway established by clearing the mouth, then the nose by rubber bag

  26. If meconium is present in amniotic fluid, after sucking of mouth and nose we must suck a pharynx by tube after laryngoscopes

  27. If it is inadequate we must use step B. At first the tactile stimulation should be given to newborn, for example- gentle flicking of the feet or heel

  28. ABC resuscitation • or rubbing of the back

  29. If these measures are inadequate, mechanical ventilation should be initiated, using mask and bag ventilation

  30. If ventilation is adequate supplemental oxygen may be given to improve heart rate or skin colour

  31. If mechanical ventilation does not improve the respiration, heart rate or colour skin, the following step is “C”-circulation. At first the assessment of heart rate is necessary

  32. If heart rate is less than 60 beats/minute, or between 60 and 80 beats and is not improving, cardiac compression is a lower on/third of sternum • Chest compressions with two fingers

  33. ABC resuscitation • Your big fingers must be lie on the sternum, other finder should lie under the back of newborn

  34. ABC resuscitation • If heart rate is less then 80 beats per minute the cardiac compression should be continued. If heart rate is 80 beats per minute or more the cardiac compression should be stop .

  35. Following lesions may be seen after moderate & severe Asphyxia • Focal or multifocal cortical necrosis (with resultant cyatic encephalomalacia and/or ulegyria attenuation) • Watershed infarcts is boundary zones between cerebral arteries in the preterm-periventicular leucomalacia • Selective neuronal necrosis • Necrosis of thalamic nuclei & basal ganglia (status marmoratus)

  36. Respiratory Distress:Mortality/Morbidity

  37. I. Pulmonary II.Extrapulmonary Central Nervous System Cardiovascular System Gastrointestinal Tract Hematological Metabolic Infections Causes of Respiratory Disorders in newborns

  38. Clinical features of the Respiratory Disorders (Respiratory Insufficiency [RI]) in neonate • Rapid or slow respiration, apnea • Expiratory audible grunting • Subcostal and xiphoid retraction • Nasal flaring • Crepitating on deep inspiration at lung bases • Cyanosis • cardiac insufficiency, pattern ductus arteriosus (PDA)

  39. The occurrence of RD • < 30 weeks 70% infants • < 26 weeks 90% infants • Term infants 1-2%

  40. Causes of Respiratory Disorders in the newbornPulmonary: • Congenital disease of lung (aplasia, agenesia) • Choanal atresia • Lung hemorrhage • Pneumonia, Pneumotorax • Hyaline membrane disease • Aspiration of meconium, amniotic fluid, blood, milk • Transient tachipnea (RDS II type)

  41. Causes of Respiratory Disorders in the newbornExtrapulmonary Cerebraldefects of CNS • intracranial hemorrhage • nervus phrenicus palsy • birth injury, brain edema • neuromuscular disease

  42. Causes of Respiratory Disorders in the newborn • Cardiac: • Congenital heart disease • Cardiac failure • Cardiomyopathy • Persistant fetal circulation

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