1. Unit 2.1 Neo/pediatric case 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? 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. The fetal heart rate is decreasing to bradycardia and not coming back up to baseline.

4. What else do you need to know? What else do you need to know?

5. answer 1. gestation of baby 1. gestation of baby 2.mother’s prior birth history 2.mother’s prior birth history 3. history of this pregnancy 3. history of this pregnancy 4.history of this labor 4.history of this labor L/S ratio or phospha-tidyl-gycerol levels L/S ratio or phospha-tidyl-gycerol levels Shake test of aminiotic fluid and ethonol 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. This is 28 weeks gestation. Mom is 25 year old, G2 P2. The labor was complicated by PROM. You are concerned because: You are concerned because:

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

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

10. What is the APGAR at 1 minute? What is the APGAR at 1 minute?

11. Answer: 1 at 1 minute 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% 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? You recommend what?

13. answer Intubate and ventilate the infant Intubate and ventilate the infant Instillation of artificial surfactant to reduce the severity of his IRDS type I 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? 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. 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 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%. 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? What do you suggest?

17. answer Get an arterial blood gas: Get an arterial blood gas: The pH is 7.34 the PC02 is 35 and the Pa02 is 65 torr. 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: Get a pressure ventilator set up on the following settings: IMV 45 IMV 45 PIP 13 PIP 13 PEEP 5 PEEP 5 Fi02 100% Fi02 100% Ti.30 to.5 seconds [closer to.3 if VSBW infant] Ti.30 to.5 seconds [closer to.3 if VSBW infant] Flow rate 8- 10 lpm Flow rate 8- 10 lpm And repeat the gas on these settings 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% 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? What do you want to do now?

21. Answer Get x-ray: Get x-ray: you see low volume lung with diffuse alveolar infiltrates and air bronchogram 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. An umbilical artery catheter is placed and in one hour, you get an ABG on the current settings. pH 7.33 pH 7.33 PaC02 45 PaC02 45 Pa02 48 torr Pa02 48 torr Sa02 88% [Sp02 is 88%] Sa02 88% [Sp02 is 88%] What has happened & what do you suggest? What has happened & what do you suggest?

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

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

25. answer HMD [IRDS type I] but we cannot r/o intrauterine pneumonia. 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 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. The baby is delivered 5 hours after labor started and membranes broke. It is SVVD It is SVVD What do you expect? What do you expect?

27. answer Mom has a bad track record of infant deaths. Mom has a bad track record of infant deaths. Baby is premature Baby is premature Baby is not at risk for infection Baby is not at risk for infection Even if baby wasn’t premature, he could have immature lungs 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? 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, 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 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. At birth, baby is flaccid, apnic with heart rate 95 bpm, blue centrally and peripherally. What is the APGAR? What is the APGAR? What is your intervention? What is your intervention?

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

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

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

34. If you did an L/ S ratio on this kid what results would you expect? 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 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. Mom is 45 year old WF G3 P3. gestation is 38 weeks. Stat C-section for late decells Stat C-section for late decells Membranes ruptured at 1300 and the baby wasn’t delivered till 1500 the next day. Membranes ruptured at 1300 and the baby wasn’t delivered till 1500 the next day. Mom is febrile with respiratory infection Mom is febrile with respiratory infection What are the maternal risks, what are we worried about ? What are the maternal risks, what are we worried about ?

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

38. answer APGAR’s and Silverman’s APGAR’s and Silverman’s Tracheal aspirate for culture and sensitivity Tracheal aspirate for culture and sensitivity Spinal tap and blood cultures for sepsis Spinal tap and blood cultures for sepsis Breath sounds and pulse oximetry 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’ 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? How do you assess this infant?

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

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

42. What else do you want to assess? What else do you want to assess?

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

44. What do you want to do? 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% 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. 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 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? 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 better in the next 6 hours, we can assume he has TTN If he gets worse, he might have mild HMD If he gets worse, he might have mild HMD Consider cardiology consult if the cardiomegally doesn’t resolve in a few hours 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. 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? What else do you need to know about this patient?

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

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

51. answer You hope she suctioned below the cords before the baby took the first breath You hope she suctioned below the cords before the baby took the first breath

52. Why? Why?

53. answer You hope she got all the meconium out of the airway because it can cause: You hope she got all the meconium out of the airway because it can cause: Bacterial infection Bacterial infection Chemical pneumonitis Chemical pneumonitis Airtrapping and pneumothorax Airtrapping and pneumothorax

54. The baby is SGA term infant who presents in the NICI entubated with a 3.0 endotracheal tube. She is being bagged at a rate of 40 bpm at a PIP of 14 and an Fi02 50%. The baby is SGA term infant who presents in the NICI entubated with a 3.0 endotracheal tube. She is being bagged at a rate of 40 bpm at a PIP of 14 and an Fi02 50%. How do you assess her? How do you assess her?

55. answer We need to listen to breath sounds to make sure she has plenty of time to exhale We need to listen to breath sounds to make sure she has plenty of time to exhale We need ABG to assess effectiveness of her current settings We need ABG to assess effectiveness of her current settings We need a chest x-ray to assess the airtrapping We need a chest x-ray to assess the airtrapping

56. The doctor orders a blood gas on the right radial and one off the left. The doctor orders a blood gas on the right radial and one off the left. What is the reason for this action and what would be significant results? What is the reason for this action and what would be significant results?

57. answer We need pre and post-ductal Pa02 to monitor to r/o right to left shunting and persistent fetal circulation [PFC]. We need pre and post-ductal Pa02 to monitor to r/o right to left shunting and persistent fetal circulation [PFC]. If there is more than 15 torr difference then we have: If there is more than 15 torr difference then we have: Patent ductus arteriosus due to low Pa02 Patent ductus arteriosus due to low Pa02 Pulmonary HTN due to low PA02 Pulmonary HTN due to low PA02 FO can reopen due to increased RA pressure FO can reopen due to increased RA pressure Patient will have PFC Patient will have PFC

58. The Pa02 on the right radial is 75 torr and the Pa02 on the left radial is 58 torr The Pa02 on the right radial is 75 torr and the Pa02 on the left radial is 58 torr How do we treat this patient? How do we treat this patient?

59. answer Treat PFC with increased ventilation to flip the patient into respiratory alkalosis and increase the Fi02 to get the Pa02 above 60 so that the ductus can close and you can reverse pulmonary HTN Treat PFC with increased ventilation to flip the patient into respiratory alkalosis and increase the Fi02 to get the Pa02 above 60 so that the ductus can close and you can reverse pulmonary HTN

60. While doing what you have to do to reverse the PFC, Do you see any problems with this particular infant? While doing what you have to do to reverse the PFC, Do you see any problems with this particular infant?

61. answer Yes, this infant should be ventilated conservatively to prevent a tension pneumonthorax but we have to reverse the PFC. Yes, this infant should be ventilated conservatively to prevent a tension pneumonthorax but we have to reverse the PFC.