Festijo

Festijo

• Boy S.F• Delivered via NSD• 32 y/o G2P1 (1011)• 39 5/7 weeks AOG, MT

39 AGA• AS 8,9

• BW 3265g• BL 49cm• HC 36cm• CC 33cm• AC 30cm

Maternal History:- PROM 18 hours prior to delivery

Ob History:- G1 – 2008, abortion at 7 weeks s/p D&C

Pertinent PE

• Caput• Good cry and activity• Clear amniotic fluid• Flat and open fontanelles• Good air entry, no retractions• Grade 1-2 systolic murmur• Soft abdomen• Grossly male genitalia with urine output• Full pulses

Diagnosis

• Term baby Boy

Course in the WardsS O A P

2nd hour of lifeCyanosis

HR 150 RR 50s O2 sat 70% at room airGood cry and activityAdynamic precordium gr 2/6 systolic murmur at left parasternal borderFull pulses

Persistent Pulmonary Hypertension vs Cyanotic Heart diseaseSepsis, unspecified

- Refer to Neonatologist

- Refer to Pediatric cardiologist

- Hook IV line- Hyperoxia test- Start antibiotics- Transfer to level

3


3rd hour of life RR 76ActiveGood cry and activity, retractions, gruntingGr 2/6 systolic murmurSoft abdomenFull pulses


- CBC, CRP- Hgt- Chest xray to

rule out Pneumonia

- Hook to O2 at 3 LPM

ABG 6LPM

pH 7.287

pCO2 31.4

pO2 92.8

HCO3 15

O2 96%

BE -10.3 Hgb Hct WBC Bands Neu Lym Mon Eos Plt

184 55 21.1 2 70 21 6 1 190

CRP = 0.02 mg/dL

Hgt = 115

Bcs: No growth after 7 days

CXR


8th hour of life HR 139 RR 61 T 37.4 O2 sat 100% 3LPM


- Decrease O2 support at 1LPM


9th hour of life Desaturations as low at 70% at 1LPM


- Increase O2 support at 2LPM

- For 2d Echo to determine cardiac pathology

- Give midazolam for sedation


12th hour of life Desaturations as low at 70% at 1LPM


- For Intubation


12th hour of lifes/p intubation

Fr 3.5Level 10Good and equal air entrySoft abdomenFull pulses

Persistent Pulmonary Hypertension;Pneumonia

- Mech ventilation settings

- FiO2 100- PIP 20- PEEP 6- IT 0.4- RR 70- For HGT- Insert UVC- Shift antibiotics

to Cefotaxime

ABG 6LPM 2/181 hr post intubation

pH 7.287 7.346

pCO2 31.4 44.6

pO2 92.8 97.9

HCO3 15 24.4

O2 96% 96.9

BE -10.3 -1.2

2d Echo: Elevated estimated right ventricular and pulmonary pressures; flattened interventricular septum and TR het of 61 mmHg (systolic BP of 71 mmHg) + right atrial pressureModerate right ventricular dilationMild ventricular hypertrophyGood biventricular systolic functionLarge bidirectional PDANo pericardial effusion

CXR


2nd day of lifeIntubatedNPONo desaturationsNo cyanosis

T 37.1 RR 71JaundiceGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDA;Sepsis, unspecified

- Reinsert OGT- Start breastmilk

feeding 3ml every 3 hours

- Start phototherapy

- Revise mech vent

- FiO2 100- RR 60- Itime 0.5- PIP 18- PEEp 5


2/19 FiO2 100 PEEP 5, PIP 20 RR 60

pH 7.287 7.346 7.397

pCO2 31.4 44.6 54.3

pO2 92.8 97.9 46.6

HCO3 15 24.4 33.3

O2 96% 96.9 81.8

BE -10.3 -1.2 7.7

2/19

Crea 0.57

iCal 0.98

Na 135

K 3.7


3rd day of lifeIntubatedTolerates 3ml of milk via OGTNo desaturationsNo cyanosis

HR 118-145RR 60-74BP 61-72/29-45O2 sat 96-100%Jaundice to chestGood air entryGood cardiac toneSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDAHyperbilirubinemia, unspecified;Sepsis, unspecified

- Mech vent settings:

- FiO2 70- RR 60- PIP 16- PEEP 4- Increase

feedings to 5ml every 3 hours


4th day of lifeIntubatedTolerates 5ml of milk via OGTNo desaturationsNo cyanosis

RR 58-73O2 sat 94-100%No alar flaringJaundice to chestShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDA;Hyperbilirubinemia, unspecified;Sepsis,unspecified


- FiO2 50- RR 40- PIP 16- PEEP 4- SIMV- Increase


- Avoid vigorous suctioning

- For VBG, Na, K, Ical, DBIB


2/19 FiO2 100 PEEP 5, PIP 20 RR 60

2/21 FiO2 40 PEEP 4 PIP 16 RR 30

pH 7.287 7.346 7.397 7.352

pCO2 31.4 44.6 54.3 56.8

pO2 92.8 97.9 46.6 42.8

HCO3 15 24.4 33.3 31.5

O2 96% 96.9 81.8 74.8

BE -10.3 -1.2 7.7 5.1

2/19 2/21

Crea 0.57

iCal 0.98 1.33

Na 135 135

K 3.7 4.4

Total Bilirubin 14.49 LIRZ

Direct Bilirubin 0.73

Indirect Bilirubin 14.08



RR 51-62HR 125-151O2 sat 92-96%Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia, unspecified


- FiO2 35- RR 25- PIP 15- PEEP 4- SIMV- Increase


- Transfer to isolette



RR 58-71HR 108-145O2 sat 92-96%Light Jaundice to faceNo alar flaringShallow subcostal retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia

- For extubation- Hook to CPAP


7th-11th day of lifeCPAPTolerates 30ml of milk via OGTNo desaturationsNo cyanosis

RR 48-64HR 110-152O2 sat 95-100%Light Jaundice to chestNo alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecifiedHyperbilirubinemia

- Continue feedings

- Possible weaning off CPAP


12-15th day of lifeTolerates 30ml of milk via OGTNo desaturationsNo cyanosis

RR 48-55HR 110-152O2 sat 95-100%No alar flaringNo retractionsGood air entryRegular cardiac rhythmSoft abdomenFull pulses

Persistent Pulmonary Hypertension;PDAPneumoniaSepsis,unspecified, resolvedHyperbilirubinemia, resolved

- Continue feedings

PERSISTENT PULMONARY HYPERTENSION

Definition

• Persistent Fetal Circulation (PFC)• Pulmonary hypertension resulting in severe

hypoxemia secondary to right-to-left shunting through the foramen ovale and ductus arteriosus in the absence of structural heart disease

Typically seen in:

• Full term or post term infants

• 37-41 weeks gestational age

• within the first 12-24 hours after birth.

In Utero

• Fetal gas exchange occurs through the placenta instead of the lungs.

• PVR > SVR causes blood from the right side of the heart to bypass the lungs through the ductus arteriosus and foramen ovale.

Fetal Shunts

• Ductus arteriosus– R-L shunting of blood from pulmonary artery to

the aorta bypasses the lungs.– Usually begins to close 24-36 hours after birth.

• Foramen ovale– Opening between left and right atria.– Closes when there is an increased volume of blood

in the left atrium.

At Birth

• First breath– Decrease in PVR– Increase in pulmonary blood flow and PaO2

• Circulatory pressures change with the clamping of the cord.– SVR >PVR allowing lungs to take over gas

exchange.– If PVR remains higher blood continues to be

shunted and PPHN develops.

Signs of PPHN

• Infants with PPHN are born with Apgar scores of 5 or less at 1 and 5 minutes.

• Cyanosis may be present at birth or progressively worsen within the first 12-24 hours.

Later developments

• Within a few hours after birth– tachypnea– retractions– systolic murmur– mixed acidosis, hypoxemia, hypercapnia

• CXR– mild to moderate cardiomegaly– decreased pulmonary vasculature

Pulmonary Vasculature

• Pulmonary vascular bed of newborn is extremely sensitive to changes in O2 and CO2.

• Pulmonary arteries appear thick walled and fail to relax normally when exposed to vasodilators.

• Capillaries begin to build protective muscle. (remodeling)

Diagnosis

• Hyperoxia Test• Place infant on 100% oxyhood for 10 minutes.– PaO2 > 100 mmHg parenchymal lung disease– PaO2= 50-100 mmHg parenchymal lung disease

or cardiovascular disease– PaO2 < 50 mmHg fixed R-L shunt cyanotic

congenital heart disease or PPHN

Hyperoxia Test (cont.)

• If fixed R-L shunt – need to get a preductal and postductal arterial

blood gases with infant on 100% O2.• Preductal- R radial or temporal artery• Postductal- umbilical artery

– If > 15 mmHg difference in PaO2 then ductal shunting

– If < 15 mmHg difference in PaO2 then no ductal shunting

Treatment

• Goals:– To maintain adequate oxygenation.• These babies are extremely sensitive• Handling them can cause a decrease in PaO2 and

hypoxia• Crying also causes a decrease in PaO2

• Try to coordinate care as much as possible– To maintain neutral thermal environment to

minimize oxygen consumption.

Mechanical Ventilation

• TCPLV (Time cycled pressure limited ventilation) may be used with PPHN.

• Want to use low peak inspiratory pressures • Monitor PaO2 and PaCO2 with a

transcutaneous monitor

Hyperventilation

• Hyperventilation helps promote pulmonary vasodilation

• Respiratory Alkalosis- decrease PAP to level below systemic pressures to improve oxygenation by helping to close the shunts– Try to keep pH =7.5 and PaCO2 = 25-30– Alkalizing agents - sodium bicarbonate or THAM

Hyperventilation (cont.)

• Babies often become agitated when they are hyperventilated

• May need to administer muscle relaxants and sedation– usually given pancuronium and morphine• pancuronium- q 1-3 hours IV at 0.1-0.2 mg/kg• morphine- continuous infusion 10 micrograms/kg/hr

Nitric Oxide (NO)

• Potent pulmonary vasodilator– decrease pulmonary artery pressure– increase PaO2

• Does not cause systemic hypotension• NO more effective in PPHN babies without

lung disease• Baby must be weaned slowly off NO or may

have rebound hypertension

Effects of NO

• NO is metabolized to nitrogen dioxide (NO2) which can cause acute lung injury.

• NO2 is potentially toxic.• NO reacts with hemoglobin to form

methemoglobin.

Outcome

• PPHN may last anywhere from a few days to several weeks.

• Mortality rate is 20-50%.– Decreased by HFOV and NO– Decreased by ECMO

• Babies treated with hyperventilation may develop sensorineural hearing loss.

THANK YOU!

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