1. The Very Low Birth Weight Infant Dana Rivera, M.D.

2. Delivery A 800 gram female infant at 26 weeks Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption

3. Resuscitation Baby pale, no respiratory effort, HR 60 Requires intubation with PPV with gradual increase in HR Transferred to NICU Perfusion remains poor with pallor

4. ETT size selection – < 1kg: 2.5 – 1-2 kg: 3.0 – 2-3 kg: 3.5 – > 3 kg: 4 Position? – between clavicles and carina

5. Umbilical lines? UVC – Intrathoracic IVC – Just above diaphragm UAC – High: T6-9, T7-10 – Low: below L3

6. Initial Hours

7. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

8. Surfactant Deficiency Syndrome Signs and Symptoms Respiratory distress – tachypnea – grunting – retractions – flaring – coarse breath sounds – mixed acidosis – hypoxia CxR: ground glass underinflation air bronchograms

9. Surfactant Deficiency Syndrome Physiology Made by? – Type II pneumocytes Detected by? – ~23 weeks, inadequate until ~32 weeks Made of? – 70-80% phospholipids Works by? – Prevents high surface tension

10. Laplace’s Law Pressure = 2x tension/ radius If surface tension equal smaller alveolus empties into larger alveolus Surface tension of different sized alveoli not constant- smaller alveoli have lower surface tension

11. Surfactant Deficiency Syndrome Management Prevention Respiratory support Surfactant replacement – Side effects Antibiotics Maintain Hct

12. Day # 2 NPO, placed on IVF or TPN?? Total fluid goal greater or less than term infant?? Why? Determining ongoing fluid needs??

13. Day #4 Increased ventilator support overnight ABG: 7.22/50/50/16/-7 Murmur

14. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

15. Patent Ductus Arteriosus Signs and Symptoms Murmur Widened pulse pressure Hyperactive precordium Bounding pulses Metabolic acidosis

16. PDA- Pathophysiology L  R shunt – Pulmonary congestion – L-sided overload – CHF Diagnosis – ECHO

17. PDA- Management – Medical Fluid restriction Diuretics Indomethacin – Contraindications – Surgical Medical failure Critical status Contraindication to indomethacin

18. Day #6 S/P indomethacin without complications; f/u ECHO reveals closed ductus Weaned to low ventilator support (IMV15, 15/4, 30%) Nurses report episodes of bradycardia (60s) which respond to bagging – What are you thinking?

19. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

20. Apnea of Prematurity Cessation of breathing > 15 sec duration with desaturation/ bradycardia Central, obstructive, mixed Methylxanthine tx – Caffeine

21. Caffeine Stimulates medullary respiratory center Increased sensitivity to CO2 Enhanced diaphragmatic contractility Diuretic Enhanced catecholamine response – Increased cardiac output/ HR Increased glucose (glycogenolysis) GER

22. Day #7 What is the one test you should order today??

23. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

24. Intraventricular Hemorrhage Signs and Symptoms Catastrophic – bulging fontanelle – posturing – seizures – apnea – hypotension – metabolic acidosis – drop in Hct – death Saltatory – Cycle of deterioration and recovery Silent: 50%

25. Intraventricular hemorrhage (IVH) Pathophysiology Germinal matrix – Developmental area of brain – Periventricular b/w caudate nucleus and thalamus – Provides neurons/ glial cells – Richly vascularized/ loose supportive stroma – Dissipates by term – Poor control of cerebral blood flow

27. IVH Grade I – Germinal matrix only (subependymal) Grade II – Intraventricular/ normal ventricles Grade III – IVH + dilated ventricles Grade IV – IVH + parenchymal bleed Screening head u/s – < ~34 weeks Management – Supportive, ventricular taps, reservoirs, VP shunts Prognosis

28. Day #14 2 spits yesterday of small amount of formula 10cc bilious residual this am on premature formula (16cc q3hr)

29. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

30. NEC- Signs and Symptoms Abdominal – distension, tenderness, discoloration, mass Feeding intolerance – Vomiting (bilious), gastric residuals, heme (+)/ bloody stools Systemic – Lethargy, apnea, poor perfusion, temp instability Labs – reflect sepsis – leukocytosis/ leukopenia, – L shift – thrombocytopenia – acidosis – hypo/hyperglycemia – hypoxia/hypercapnea

31. NEC- radiograph Pneumatosis intestinalis thickened bowel wall sentinel loop “soap bubble” appearance (RLQ)

32. NEC Pneumoperitoneum Portal venous air

33. NEC- Pathophysiology Onset? – 3-10 days (24hr- 3mo) Where? – Jejunum, ileum, colon What? – Bowel necrosis, edema, hemorrhage, perforation Etiology? – Multifactorial – GI dysmotility/ stasis – Partially digested formula substrate for bacterial proliferation – Mucosal injury/ bacterial invasion – Mesenteric ischemia – Inflammatory mediators

34. NEC- Management Medical – Bowel rest – Decompression – Broad spectrum Abx – Serial radiographs – Fluid/ nutritional support – Blood product support – BP support – Respiratory/metabolic support Surgical – Pneumoperitoneum, fixed abdominal mass, persistently dilated loop, abdominal discoloration, persistent clinical deterioration – Resection of necrotic bowel with ostomy – Peritoneal drain

35. Day # 38 S/P NEC, no perforation, feedings resumed after 10 days bowel rest with elemental formula, reached full feeds 4 days ago Now extubated, remains oxygen dependent

36. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

37. Chronic lung disease (CLD or BPD) Treatment with oxygen >21% for at least 28 days plus— Mild BPD: Breathing room air at 36 weeks postmenstrual age (PMA) or discharge Moderate BPD: Need for <30% oxygen at 36 weeks PMA or discharge Severe BPD: Need for 30% oxygen and/or positive pressure (ventilation or continuous positive airway pressure) at 36 weeks PMA

38. BPD- Pathophysiology

39. Day #38 What should have been ordered by now??

40. Diagnosis BPD IVH PDA ROP ROS SDS AOP NEC

41. Retinopathy of prematurity (ROP) Risk factors? – Prematurity, oxygen exposure Vasoconstriction  vaso-obliteration  neovascularization Classification – Stages 1-5 – Zones I-III

42. ROP- Stages & Zones 1: Demarcation line 2: Ridge formation 3: Neovasculariztion/ proliferation 4: Partial retinal detachment 5: Complete retinal detachment Plus disease – Tortuous arterioles, dilated venules Higher stage, lower zone- worse disease state

43. ROP screening < 1500gm or 32 weeks Selected infants >1500gm, > 32 weeks AAP policy statement – Pediatrics 117(2), 2/06

44. Gestational agePostmenstrualChronologic 22319 23318 24317 25316 26315 27314 28324 29334 30344 31354 32364

45. Who is the most famous person affected by ROP?