Transcript ภาพนิ่ง 1 - Mahidol University
Extern Conference 30 Aug 07
Case Study
A Thai male infant Tachypnea and Dyspnea at 2 hrs after birth
History
• Maternal age 35 years • G 1 P 0 A 0 ,GA 40 +2 wks by date • Serology: negative for anti HIV ,VDRL and HBsAg • Blood group: O, Rh + • Complication during pregnancy : • GDM A1 • Hb E trait ( Paternal: normal Hb typing ) • Gestational hypertension on Aldomet (125) 1x3 • No family history of early neonatal death
History
• • • • • Poor ANC Spontaneous ROM 5 hrs: Thick meconium • C/S due to CPD and Thick meconium • Term AGA male infant (20/8/2550 9.21am) Vigorous baby ETT suction - Meconium at the tip of ETT OG aspiration - Meconium 10 ml
History
• Resuscitation: Oxygen tubing and stimulation • Apgar score: 8(-color 2) ,9(-color 1) • Vital signs: T 37.2 o C RR 80/min • BW 3520 gm, HC 35 cm, Lt 50 cm • Transfered to nursery, via incubator with oxygen hood, and oxygen flow 5 LPM, due to tachypnea
Physical examination
• V/S: T 37.1 o C, HR 163 bpm, RR 64/min , BP 68/45 mmHg • GA: active, grunting, suprasternal retraction, dyspnea, tachypnea , no cyanosis, no jaundice • CVS: normal S1, S2, no murmur • RS: no increase in AP diameter, secretion sound both lungs • Abd: soft, no abdominal distension, active BS, liver and spleen cannot be palpated • Neuro: symmetrical movement • Extremities: no deformity • Genitalia: Male type ,descended testes
Problem list
1. Advanced maternal age 2. Poor ANC 3. Maternal GHT & GDM A1 4. Thick meconium stained amniotic fluid With evidence of meconium in trachea 5.
Respiratory distress at 2 hrs after delivery
Differential Diagnosis
Differential Diagnosis
• Meconium aspiration syndrome • Transient tachypnea of the newborn • Pneumonia
Differential Diagnosis
Meconium aspiration syndrome
• Pro: - Respiratory distress early after delivery - Hx of Thick meconium stained amniotic fluid - Evidence of meconium in the trachea - Maternal GDM, HTN - Secretion sound both lungs • Con: Not posterm, SGA or depress at birth - Not increase in chest AP diameter
Differential Diagnosis
Transient tachypnea of the newborn
• Pro: - Mild respiratory distress early within 2 hrs after delivery - C/S - Maternal GDM • Con: - Not increase in chest AP diameter - Secretion sound both lungs
Differential Diagnosis
Pneumonia
• Pro: Respiratory distress early after delivery - Secretion sound both lungs • Con: - No maternal chorioamnionitis or fever - No prolonged rupture of the membranes - No hyperthermia - No neonatal depression
Neonatal Respiratory Distress
Neonatal Respiratory Distress
Signs and symptoms
• Tachypnea (RR > 60/min) • Retraction • Noisy respiration (grunt, stridor or moaning) • +/- Cyanosis • +/- Desaturation
Neonatal Respiratory Distress
Etiologies
-
Pulmonary causes
RDS Pneumonia TTNB MAS Other aspiration syndrome Air leak syndrome Lung hemorrhage Lung hypoplasia Congenital malformations -
Systemic causes
Infections Metabolic causes Temperature Anemia / Polycythemia Congenital heart disease Pulmonary hypertension Neuromuscular disorder -
Anatomic causes
Upper airway obstruction Airway malformation Space occupying lesion Rib cage anomalies Phrenic nerve injury Clinical diagnosis clues: Hx, PE and Ix
Neonatal Respiratory Distress
Algorithm
Respiratory Distress
(tachypnoea, retractions, grunt)
Preterm Term < 6hrs old > 6hrs old
HMD (RDS) Pneumonia Lung anomaly PDA Pneumonia CHD Pulm Hm
< 6hrs old
TTNB MAS/PPHN Asphyxia LungAnamoly Air leak
> 6hrs old
Pneumonia CHD
Management & Progression in this patient
Progression at nursery
• Hct 64% • CBS 81 mg% • Retained OG tube: meconium 1 ml, step feeding via OG • On O 2 hood 3 LPM and incubator: SpO 2 99% FiO 2 chest movement 0.45
SS retraction, nasal flaring, paradoxical • Portable CXR at 8 hrs 20/8/2550 18.23
8 hr after birth
Meconium Aspiration Syndrome
–
Nearly all have complete recovery
–
Few have long-term neurologic deficits due to CNS damage
The pathogene sis of MAS
Risk factors
• Post-term pregnancy • Preeclampsia • Maternal diabetes • Maternal hypertension • Difficult delivery • Fetal distress • Intra-uterine hypoxia, a condition in which a fetus receives a decreased amount of oxygen while still in the uterus
Most common symptoms
• Rapid or labored breathing • Retractions, pulling in of the chest wall • Grunting sounds with breathing • Bluish skin color, called cyanosis • Low Apgar score -- the Apgar test is given to infants just after birth to quickly evaluate their color, heartbeat, reflexes, muscle tone and respiration • The body appearing limp
Investigation
• Acid-base status • Serum electrolytes • CBC • Imaging Studies: – A chest radiograph – Later in the course of MAS when the infant is stable, imaging procedures of the brain, such as MRI, CT scan, or cranial ultrasound • Other Tests: – Echocardiogram for R/O PPHN
Meconium Aspiration Syndrome
Meconium Aspiration Syndrome
Progression at nursery
• Feeding intolerance and hyperthermia: (T37.4 c) at 15 hrs • On O2 hood 5 LPM FiO2 0.45: SpO2 98%, active, RR 80/min, SS retraction, nasal flaring, paradoxical chest movement • F/U CXR at 24 Hrs • CBC: – Hb 14.5 g/dl, Hct 41% – WBC 27,020/mm 3 (N63%, L19%, Band 13%, I:T = 0.12) – PLT 270,000/mm newborn care 3 • Transfer to intermediate (for R/O pneumonia) 21/8/2550 10.08
24 hr after birth
Progression at Intermediate newborn care
• Respiratory distress • MAS R/O secondary pneumonia • On O2 hood 5 LPM FiO2 0.45: • SpO2 98%, RR 80/min, SS retraction, nasal flaring, paradoxical chest movement • Start Ampicillin 150 mg/kg/dose, Gentamicin 4 mg/kg/dose at 2 nd DOL • 4 th DOL wean off O2 hood: SpO2 RA 96-99%, no dyspnea • H/C: no growth • Nutrition • 2 nd DOL NPO, iv fluid GPR 4.7
• 3 rd DOL Step feeding via OG tube > Try cup > Try spoon • No feeding intolerance, Wean off iv at 6 th DOL
Complications
• Persistent pulmonary hypertension • Air leak • pneumomediastinum, pneumothorax, cystic lung disease • Pulmonary haemorrhage • Complications of asphyxia • encephalopathy, seizures, oliguria, coagulopathy and thrombocytopenia • Chronic lung disease.
• Infections.
Management
1. Prevention • Monitor fetal status • Amnioinfusion • Suctioning +/- intubation and immediate suctioning • Avoid harmful techniques 2. Intervention • Optimal thermal environment & minimal handling • Respiratory care, Oxygen therapy & ECMO • Surfactant therapy • Keep stable V/S
PPHN prevention
1. Avoid vasoconstriction • Acidosis • Hypoxia • Metabolic disturbance - Hypocalcemia - Hypercalcemia - Hyperglycemia - Hypoglycemia 2. Prevent right to left shunt
Management Discussion
Guidelines of the baby exposed to meconium
Vigorous No Yes Immediate tracheal suction Clear secretions and meconium initial resuscitation steps Meconium No meconium HR>100 HR<100 reintubate and suction PPV and suction again later
The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee management guidelines of the baby exposed to meconium:
EET suction indication
• Only in non vigorous baby - depressed respirations - decreased muscle tone - heart rate < 100 beats per minute • Pharyngeal suctioning of an infant before delivery of the shoulders.
• Removal of meconium from hypopharynx and larynx by large-bore catheter.
• Endotracheal intubation for removal of meconium in the lower airway.
• Meconium aspirator attached to wall suction.
Steroid therapy for meconium aspiration syndrome in newborn infants
• The Cochrane Database of Systematic Reviews 2007 Issue 3,
The Cochrane Library
(ISSN 1464-780X • Conclusions:
At present, there is insufficient evidence to assess the effects of steroid therapy in the management of meconium aspiration syndrome
(no significant reduction in mortality, duration of hospital stay, Duration of mechanical ventilation, incidence of air leak,increase in duration of oxygen therapy was seen with the use of steroids)
Role of antibiotics in meconium aspiration syndrome
• Ann Trop Paediatr. 2007 Jun;27(2):107-13. •
Basu S
,
Kumar A
,
Bhatia BD
.
• Division of Neonatology, Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India. [email protected]
• CONCLUSION:
Routine antibiotic therapy is not necessary for managing MAS. No significant difference
– – – – – period of oxygen dependency (5.8 vs 5.9 days) day of starting feeds (4.0 vs 4.2) day of achievement of full feeds (9.4 vs 9.3) clearance of chest radiograph (11.7 vs 12.9 days) duration of hospital stay (13.7 vs 13.5 days)
Surfactant for meconium aspiration syndrome in full term/near term infants
• • Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002054
El Shahed A
,
Dargaville P
,
Ohlsson A
,
Soll R
.
• CONCLUSIONS: In infants with MAS, surfactant administration may reduce the severity of respiratory illness and decrease the number of infants with progressive respiratory failure requiring support with ECMO. The relative efficacy of surfactant therapy compared to, or in conjunction with, other approaches to treatment including inhaled nitric oxide, liquid ventilation, surfactant lavage and high frequency ventilation remains to be tested.
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Reference
Cyanosis (The Diagnostic Approach to Symptoms and Signs in Pediatrics);
http://www.wrongdiagnosis.com/symptoms/cyanosis/book causes-15a.htm
Overview of neonatal respiratory distress: Dsorder of transient
: Up to date
Neonatal Respiratory Distress: Radiologic Approach,
Simon C.S. Kao, M.D.; http://www.radiology.uiowa.edu/Radshortclerkship/RadShortClkship/ LectureNotes/Kao.htm
Management of Respiratory Distress in the Newborn
Surg Cdr SS Mathai, Col U Raju; MJAFI 2007 ;63 : 269-272
The epidemiology of meconium aspiration syndrome: incidence, risk factors, therapies, and outcome
. Dargaville PA , Copnell B ; Australian and New Zealand Neonatal Network . Pediatrics. 2006 May;117(5):1712-21.
Role of antibiotics in meconium aspiration syndrome
.
Basu S , Kumar A , Bhatia BD . Ann Trop Paediatr. 2007 Jun;27(2):107-13.
Inflammatory markers in meconium induced lung injury in neonates and effect of steroids on their levels: a randomized controlled trial.
Tripathi S
, Saili A , Dutta R . Indian J Med Microbiol. 2007 Apr;25(2):103-7.
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Reference
Role of Steroids on the Clinical Course and Outcome of Meconium Aspiration Syndrome--A Randomized Controlled Trial
. Basu S , Kumar A , Bhatia BD , Satya K , Singh TB . J Trop Pediatr. 2007 May 29; [Epub ahead of print
The effect of steroids on the clinical course and outcome of neonates with meconium aspiration syndrome
. Tripathi S , Saili A . J Trop Pediatr. 2007 Feb;53(1):8-12. Epub 2006 May 16
Surfactant for meconium aspiration syndrome in full term/near term infants.
El Shahed A , Dargaville P , Ohlsson A , Soll R . Cochrane Database Syst Rev. 2007 Jul 18;(3):CD002054
Surfactant replacement therapy
. Stevens TP , Sinkin RA . Chest. 2007 May;131(5):1577-82
ECMO for meconium aspiration syndrome: support for relaxed entry criteria.
Radhakrishnan RS , Lally PA , Lally KP , Cox CS Jr . ASAIO J. 2007 Jul-Aug;53(4):489-91
Therapeutic lung lavage in meconium aspiration syndrome: a preliminary report
. Dargaville PA , Mills JF , Copnell B , Loughnan PM , McDougall PN , Morley CJ . J Paediatr Child Health. 2007 Jul-Aug;43(7 8):539-45
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Bronchoalveolar lavage with diluted porcine surfactant in mechanically ventilated term infants with meconium aspiration syndrome
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Inhaled nitric oxide treatment inhibits neuronal injury after meconium aspiration in piglets
. Aaltonen M , Soukka H , Halkola L , Jalonen J , Kalimo H , Holopainen IE , Kääpä PO . Early Hum Dev. 2007 Feb;83(2):77-85. Epub 2006 Jun 21
Morphological alterations of exogenous surfactant inhibited by meconium can be prevented by dextran
. Ochs M , Schüttler M , Stichtenoth G , Herting E . Respir Res. 2006 Jun 6;7:86.
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. Xu H , Hofmeyr J , Roy C , Fraser WD . BJOG. 2007 Apr;114(4):383-90
ACOG Committee Opinion Number 346, October 2006: amnioninfusion does not prevent meconium aspiration syndrome
. ACOG Committee Obstetric Practice . Obstet Gynecol. 2006 Oct;108(4):1053