Case Studies Neonates By Nicole Stevens Case Studies

Case Studies - Neonates By: Nicole Stevens

Case Studies - Neonates • • Haemolytic disease of the newborn (Baby Eric) Hyperbilirubinaemia Hypoglycaemia (Case 1 and 2) Birth asphyxi/HIE Sepsis RDS/pneumothorax The undiagnosed cardiac abnormality in a level 2 facility • The 24 -26 wker born in a non-tertiary facility

1. Case Study: Baby Eric Maternal history: • Gravida 5, Para 4 (after birth of Eric) • Blood group O+ve; anti-c, anti-e antibodies pos • GBS neg, Hep B/syph/HIV neg • Hep C pos • Smoker (15 day) • Normal morphology scan; 32/40 scan showing asymmetrical growth restriction

2. Case Study: Baby Eric • • • Induction of labour for IUGR & polyhydramnios 16/5 @ 1225 hrs, Normal vaginal birth Live born male, Apgars 9@1, 9@5 mins 36. 6 wks, Birth weight: 2600 gs Transferred to postnatal ward for ongoing care Mother planning to breastfeed

3. Case Study: Baby Eric • 17/5 On examination by midwife at 33 hrs of age, noted to be jaundiced. • Had been feeding 2 -3/24; had not passed mec since birth • SBR taken: 228 micromol/L (in exchange range); paediatric team notified • Seen by paed, admitted to SCN, quadruple phototherapy lights commenced

4. Case Study: Baby Eric Plan (17/5): • Feed to maintain TFI at 80 m. L/kg; EBM/formula 3 x 8 • Bloods to be taken in 4 hrs (Blood group, coombs and repeat SBR) • Monitor abdomen, notify paeds of distention or feed intolerance. Note: large mec stool passed shortly after admission to SCN

5. Case Study: Baby Eric • SBR 4 hrs later (37 hrs): 212 (out of exchange range); passing concentrated urine Plan: • Continue quadruple lights, remain in isolette • Repeat SBR in 6 hrs: 178 (out of phototherapy range) Plan (18/5): • Feeds increased to 100 m. L/kg • Reduce to double phototherapy Note results back from group and coombs: O Pos, pos coombs, anti-Ig. G pos, anti-C 3 neg

6. Case Study: Baby Eric Plan 19/5 – 20/5 (day 4 – 5): • Increased TFI to 120 m. Ls/kg • Out of isolette for feeds • Mum suppressed lactation, bottle feeding on Nan. Ha • Daily blood tests continuing • Baby examining well, alert vigorous, fully suck feeding. Normal weight loss post birth

7. Case Study: Baby Eric Plan 19/5 – 20/5 (day 4 – 5): • Increased TFI to 120 m. Ls/kg • Out of isolette for feeds • Mum suppressed lactation, bottle feeding on Nan. Ha • Daily blood tests continuing • Baby examining well, alert vigorous, fully suck feeding. Normal weight loss post birth

8. Case Study: Baby Eric • Day 6 down to single lights. Continue daily bloods, regular feeds • Day 10 back up to triple lights. • Day 11 back to birth weight. • Day 12 decrease to double lights

9. Case Study: Baby Eric • Day 13 continuing decrease in Hb, pale, slightly lethargic, but haemodynamically stable • Given blood transfusion. IV bung inserted and given 50 m. Ls PRBC (19 m. L/kg), expected to raise Hb by 4. 7 g/d. L • 6 grams intragram P also given, IV, over several hours

10. Case Study: Baby Eric • Day 14 reduced to single lights • Day 15 phototherapy ceased • Home day 18 with paediatric clinic follow up with repeat Hb and retics prior to this appointment • Discharge wt: 2790 g, 39. 3 wks CA • Discharge medications: Folate and ferrous suphate daily.

11. Pathology summary Date 17/5 18/5 19/5 20/5 21/5 22/5 23/5 24/5 25/5 26/5 Time 0945 0500 1220 1030 0930 1143 0910 0805 0945 1130 1050 SBR Hb 228/6 212/6 16. 8 178/6 192/12 291/8 233/7 207/7 263/7 244/10 11. 6 262/29 294/33 10. 1 other Hct 48. 8%, plat 225 Opos, coombs pos, anti-Ig. G: pos anti-C 3: neg

12. Pathology summary Date 27/5 28/5 29/5 30/5 1/6 3/6 19/6 6/7 25/8 19/9 Time SBR Hb other 0800 280/8 0830 258/16 8. 6 1200 233/35 6. 9 PRBC transfusion 1000 182/8 10. 9 1155 101/14 10. 4 0730 84/8 10. 8 DISCHARGED HOME (outpt f/up) 8. 4 retics 3. 1% 8. 6 retics 2. 6% 11. 4 13. 5

13. Considerations • Communication from antenatal care providers to paediatric team regarding maternal anti-e, anti-c antibodies • Early screening of SBR (cord blood) • Closer monitoring and awareness in first 24 hrs • Physiological v’s Pathological jaundice • Early onset jaundice can be a neonatal emergency • Haemolytic disease of the newborn • Action of phototherapy

CASE STUDY: HYPERBILIRUBINAEMIA BY: NICOLE STEVENS

Case study • • • Multipara G 3 P 2, 39+2 wks gestation Repeat elective caesarean section booked O+ve, antibodies neg, rubella immune GBS –ve, well through pregnancy No other history of note

Case Study • • Date of birth 29/7/11 Time of birth 0930 hrs Live female infant Born via EL LUSCS Apgars 6@1 min, 10@5 mins To postnatal ward for routine care Weight 3590 g

Case Study • • • Noted to be jaundiced at 26 hrs of age SBR taken: 188/12 (30/07/11 @ 1130 hrs) Just at treatment line Double phototherapy commenced Breast feeds + 90 m. L/kg topups Further bloods taken at 2020 hrs (35 hrs old): SBR: 186/12. Going away from treatment line (below) • Blood group: A+ve, DAT: positive, Hb: 12. 9, WCC: 25. 5, Platelets: 267

Case Study • • Double lights continued Bloods repeated 31/7 @ 0615 hrs (45 hrs old): SBR: 158/9 • Phothotherapy ceased • Bloods repeated 12 hrs later: SBR 168/11 • Remained out of lights • Bloods repeated 24 hrs later (69 hrs old): SBR: 171/12, Hb: 12. 7 • Minimal rise, unconcerning

Case Study • • Mum suppressed lactation Discharged home Day 4, bottle feeding Followed up by DOM service No further issues • NICE guidelines currently the tool in use in SCN at BHS, other places will have different tools which will slightly alter the treatment ranges. (National Institute for Health and Clinical Excellence: treatment threshold graphs for babies with neonatal jaundice).

ABO incompatability • A common and generally mild type of haemolytic disease in babies • Occurs, usually, with an O group mum and an A or B group baby • Prem babies will be more severely affected than healthy term babies. • Does not become more severe in future pregnancies (such as with the negative blood group mothers)

ABO incompatability Review of blood types: • The genes you inherit from your parents determine your blood group; there are 4 (major) types: A, B, AB & O • Each type has an individual collection of chemicals on the blood cell surface, known as antigens • A has A antigen, B has B antigen, AB has both and O has none • If different blood types mix, an immune response occurs and antibodies will be produced to attack the foreign antigen

ABO incompatability • Generally during pregnancy mother and fetus’ blood doesn’t mix, but it can (miscarriage, trauma, birth and sometimes for unknown reasons) • The O group mum may produce antibodies against an A, B or AB group baby, these antibodies can cross the placental membrane and increase the rate of haemolysis (cause red blood cell destruction), hence increasing the production of bilirubin – a waste product

Jaundice and length of stay • Readmit from home, dehydrated, no underlying haemolytic disease – if treated and fed usually only 24 – 48 hrs stay required. Increase education to parents, if breastfeeding, provide lactation support • Premature baby, may be a reoccurring problem over first 1 – 2 weeks of life, usually resolved by the time baby otherwise ready for home • Pathological/haemolytic cause: can be protracted length of treatment over 1 – 2 wks (sometimes longer), with rebounds. Long term anaemia may result in need for top up transfusions. • Breast milk jaundice: months, low levels persisting over prolonged period of time, not usually requiring treatment beyond the first 1 – 2 weeks. Diagnosed by exclusion after several weeks.

Nursing Care • Educate parents • Maximise time under lights and surface area exposed (lights above and below in more severe cases). Big nappies covering half the body need to be folded down/minimised; don’t over nest and reduce exposure to lights. • Consider nappy off & staying in incubator to feed in pathological cases (in early days if levels high) • If coming out for feeds, keep it brief. • Eye care • Skin care • Feeding support/establishment of lactation

Case study 1 continued • • Neonate of gestational diabetic mother Poor control of diabetes in pregnancy Prematurity Large for gestational age (? High levels of circulating insulin): above the 97 th centile for a baby of this gestation • Respiratory distress • Sick baby/anaemic

Case 1 • 32 yr old multi presented to hospital in the Gippsland region, with history of decreased fetal movements (32. 4 wks gestation), CTG showed sinusoidal trace – EM LUSCS performed • Antenatal history: poorly controlled GDM on insulin; pregnancy induced cholestasis; antenatal depression (medicated); fetus estimated to be on the 98 th centile and polyhydramnios evident • Steroids given just prior to delivery

Case study 1 cont… • Baby Beau born at 1530 hrs via EM LUSCS (3300 gs) • Noted to be pale, irregular respirations/periods of apnoea – CPAP/IPPV given intermittently until breathing regularly. • Nasal CPAP commenced at 40 mins of age with a PEEP of 5 cm H 20, Fi. O 2: 45% • Umbilical p. H 7. 13 venous, 7. 21 arterial • FBE, CRP, BC, electrolytes, ABG and BSL taken • APGARS: 5, 4, 4, 4 @ 1, 5, 10 & 15 mins

Case study 1 cont… • Results of interest: (at 1&1/2 hrs of age) Hb 64, ph 7. 12, CO 2 75 PEEP increased to 10 at this point • Initial BSL’s: 1. 5 & 1. 8 (received 2 x 2. 5 m. L/kg of 10% dextrose bolus’), BSL 1 hour later 2. 6 mmol/L. Infusion of 45 m. L/kg 10% dextrose commenced. • Issues: anaemia, prematurity, hypoglycaemia, LGA, respiratory distress requiring CPAP • NETS called and t/f planned to RWH • Mother and baby both A+ve, Kleihauer positive (fetal-maternal haemorrhage)

Case study 1 cont… • 12. 5% dextrose commenced by NETS • Transferred to RWH (at 6 hrs of age) with NETS intubated, received x 1 dose surfactant before t/f and one at RWH – extubated the following day. • Received a transfusion of PRBC’s • TBG’s stabilised 3. 5, 3. 8, 2. 9, 3. 4, 4. 0 etc • Hb checked post transfusion 145, next day 158

Case study 1 cont… • What were this babies risk factors for hypoglycaemia?

Case study 1 continued • • Neonate of gestational diabetic mother Poor control of diabetes in pregnancy Prematurity Large for gestational age (? High levels of circulating insulin): above the 97 th centile for a baby of this gestation • Respiratory distress • Sick baby/anaemic

Case study 1 cont. . . Other issues for this baby? ? • Low apgars, hypoxic episode, ? HIE (will discuss in later case study) • Anaemia (fetomaternal haemorrhage) • RDS (CPAP initially 5 cm, then up to 10 cm) • Too high? ? What was the reason for this? What was another option? • Intubated and given surfactant prior to transfer

Case study 1 cont. . . • Fetomaternal hemorrhage refers to the entry of fetal blood into the maternal circulation before or during delivery • Is a pathological condition with a wide spectrum of clinical variation • Secondary to the resultant anaemia, it may have devastating consequences for the fetus, such as: neurologic injury, stillbirth or neonatal death • The most common antenatal presentation is reduced fetal movements

Case study 1 cont. . . Management • Immediate delivery if acute presentation and fetal compromise evident • Consider intrauterine transfusion versus delivery based on: GA, status of fetus, availability of personnel to perform transfusion, procedural difficulty, rapid/large haemorrhage v’s slow haemorrhage • Administeroids if < 34 weeks GA

Case study 1 cont. . . • The Kleihauer-Betke test is a quantitative assay for fetomaternal hemorrhage that detects fetal red blood cells in the presence of maternal red blood cells by staining of a blood smear following acid elution. It is based on the relative resistance of fetal hemoglobin (Hb. F) for acid treatment compared to maternal adult hemoglobin (Hb. A). The results are used to calculate the dose of Rh immune globulin (Rh. Ig) to administer to an Rh negative woman for post-natal prophylaxis of Rh alloimmunization. • Sample Required: 7 ml EDTA (If postnatal sample, draw > 1 hour after delivery) • Normal Test Values: The percentage of fetal hemoglobin in adults is normally < 1%

Reference List • www. ncbi. nlm. nih. gov/pubmed/20410781 Wyle BJ & D’Alton ME. Fetomaternal hemorrhage www. psbc. org/lab_redcell/test 11. htm

Case Study No. 2 • Multipara, NVB at 40 wks gestation, born at 2044 hrs. Mec liquor present, but baby vigorous, nil resus required • Apgars of 9 and 9 • Birth weight: 4090 gs • Mother planning to breastfeed • Transferred to postnatal ward, good breast feed noted at 2130 hrs • Baby normothermic • Hep B and Vit K given

Case study 2 cont. . • On commencement of day shift, midwife noted that baby had not fed since 2130 hrs in the evening, mother confirmed same • BSL taken at 0845 hrs: 1. 2, TBG performed in SCN: 2. 3 • Baby breastfed and topped up, received 0. 5 m. L EBM and 8 m. L Nan via syringe • TBG repeated at 1045 hrs: 1. 5; baby admitted to SCN • Attempt made at suck feed, too sleepy, NGT inserted and 60 m. L/kg feed given.

Case study 2 cont… • TBG at 1210 hrs: 2. 1; d/w paeds further 30 m. L/kg feed given via NGT • TBG at 1315 hrs: 2. 1; d/w paeds, for insertion of IV bung • 1400 hrs IVB inserted 2 m. L/kg bolus of 10% dextrose given and IVT commenced at 60 m. L/kg • Baby made NBM • 1445 hrs TBG 2. 6, NBM infusion continued • 1600 hrs TBG 3. 6, NBM infusion continued • 2000 hrs TBG 3. 5, baby breast fed, IVT continued

Case study 2 cont… • Plan from this point would be to continue breastfeeding on demand, or 3 -4/24 • Continue dextrose infusion overnight • Plan to wean dextrose next day and continue to establish breastfeeding/supply • No set rules on how to wean the dextrose, could go down by 2 m. L/hr with each feed, checking an AC BSL; or could be more ‘aggressive’ and half it initially, half again and then cease. Each hospital and doctor will be different, but as long as the BSL’s are monitored as the dextrose is weaned either option above would be acceptable, or variations of the same.

Case study 2 cont. . • What are the risk factors for hypoglycaemia for this baby?

Case study 2 cont. . • Large for gestational age • Did not have blood sugar monitoring, and any baby who is greater than 4 kgs or > than the 90 th centile should have monitoring of BSL’s initially until stable • Did not receive a feed for 12 hrs

1. KH G 1 P 0 O+ve, nil antibodies Serology negative, rubella immune No abnormalities noted on US at 19+5/40 Hypertension during pregnancy SROM at 35+1 (8 hrs pre delivery), NVD, Apgars 8, 9, 9, BW 2585 g Admitted to SCN due to prematurity NG feeds commenced

2. KH Day 9 • Increased WOB and RR noted (60) • FBE CRP benign • CXR NAD • Multiple attempts at IV access unsuccessful. IM benpen/gent Day 10 • RR up to 80. Sa. O 2 91%. Temp 37. 7 • Bright red PR blood noted at nappy change 0940 • Lethargic with poor tone • Multiple attempts at IV access – scalp vein • Systolic murmur noted. Palpable femoral pulses.

3. KH • What’s your guess at a diagnosis? • Why the increased work of breathing? • Doesn’t appear to be a sepsis issue – blood tests are normal • Difficult IV access – shutdown? • PR bleeding – odd • Murmur heard • What tests, investigations are you thinking need to be done?

4. KH Day 10 22/8 • Transferred to MMC • Echo: coarctation + PDA. Prostin commenced • Treated for suspected NEC • Normal AXR • Surgical review • NBM, triple antibiotics • PR bleeding likely secondary to gut ischaemia 26/8 • Transferred to RCH • 28/8 – coarctation repair, PDA ligation • Small-mod perimembranous VSD + 2 apical muscular VSDs

5. Coarctation of the Aorta • Suspected congenital heart disease in the newborn is a medical emergency • Coarctation of the aorta is the most commonly missed congenital heart disease • It is a narrowing, or stricture of the aorta • Remain alert for this condition, especially in a neonate presenting with poor feeding, failure to thrive, or signs of heart failure • Specific physical findings include a systolic murmur, weak or absent femoral pulses, and upper body hypertension

6. Coarctation of the aorta

7. Coarctation of the Aorta • Accounts for 7% of congenital heart defects • Leads to restricted blood flow to the lower part of the circulation • Heart failure may develop • In most cases surgical repair is required, sometimes in the early weeks of life • Detection and treatment reduces the morbidity and mortality from heart failure and improves long term outcomes BEWARE: a normal result on a newborn examination does not rule out congenital heart disease

8. Diagnosis note • A harsh systolic murmur over the left sternal border indicates a 54% change of an underlying cardiac malformation • Weak or absent femoral pulses are found in 92% of infants with coarctation of the aorta, if this is noted a paediatrician should be consulted and ideally, four limb BP’s taken. • Upper limb HT has been found in 97% of infants with coarctation and a systolic BP that is > 20 mm. Hg higher in the arms than the legs is evidence of coarctation • However, a negative finding on the four limb PB measurement does not exclude the condition

9. Coarctation of the Aorta Repair: • Removal of the section with the stricture and rejoin the ends back together • Or, use the artery to the left arm to create a flap, which is turned down to enlarge the narrow section (subclavian flap) • Or, it may be possible to manage with a balloon catheter (balloon angioplasty) Conventional method is the end-end reanastomosis

10. Coarctation of the Aorta • Coarctation may also occur with other cardiac defects, typically involving the left side of the heart. The defects most commonly seen with it are: bicuspid aortic valve and ventricular septal defect (VSD) • Coarctation is common in patients with some chromosomal abnormalities, such as Turner’s syndrome • In the presence of a coarctation, the left ventricle has to work harder (increased afterload), since it must generate a higher pressure than normal to force blood through the narrow segment of the aorta to the lower part of the body. • If the narrowing is severe, the ventricle may not be strong enough and congestive cardiac failure may occur or inadequate blood flow to the organs of the body.

11. Methods of repair of a coarctation

12. Coarctation of the aorta & PDA • Coarctation occurs most commonly in a short segment of the aorta just beyond where the arteries to the head and arms take off, as the aorta arches inferiorly toward the abdomen and legs • This portion is called the juxtaductal part of the aorta (or the part near where the ductus arteriosus (DA) attaches • The DA is a vessel normally present in the fetus, it has a special tissue in its wall that helps it close in the first hours of life; it is thought that a coarctation may be caused by the presence of extra ductal tissue extending into the adjacent aorta which results in aortic narrowing as the ductal tissue contracts after birth

13. PDA Coarctation

14. Management of Coarctation • Goals are to improve ventricular function and restore blood flow to the lower body • Commence a prostaglandin infusion to open up the PDA if it had closed, and maintain it in an open state until surgery can be performed • This will allow blood to areas beyond the coarctation • It may be necessary to also begin medications to improve cardiac contractility (an inotrope) • Babies will need to be intubated and ventilated prior to surgery, if not earlier, during the period of stabilisation

15. Managing cardiac conditions in SCN’s • In the ideal world all cardiac conditions would be diagnosed antenatally and the babies would be birthed in an appropriate centre with staff prepared to manage the situation in a controlled manner • In Victoria this would mean being booked in to one of the tertiary hospitals with a NICU facility, stabilised and then transferred (usually) to RCH if it is a lesion that requires surgical repair • But… the ideal doesn’t always occur. Babies with some congenital cardiac abnormalities (that are undetected antenatally) can present well initially, even up until time of discharge may not have raised alarm bells; be sent home, and may be the baby that ‘crashes’ at home several days later (when the PDA closes) and they are in a life threatening crisis and rushed in by ambulance

16. Managing cardiac conditions in SCN’s Screening: • Morphology scan at the 20 wk mark that results in clear views of all chambers of the heart and the vessels surrounding • If suspicions raised postnatally (by murmurs, respiratory status, colour, Sa. O 2, 4 limb BP’s), consult a paediatrician • Echocardiogram • Routine screening of all babies: BHS has recently commenced routing screening of all babies of pre & post ductal Sa. O 2 prior to discharge, discrepancies are reported to a paed and management plan made.

17. Managing cardiac conditions in SCN’s Prostaglandin infusions • Suspicion of a duct dependent lesion or confirmed diagnosis, discuss with NETS and start prostaglandin if required • Will require a separate line, can be peripheral or central Eg. Of how to prepare (alprostadil 500 mcg/1 m. L amp) • Draw up 60 mcg/kg (3. 3 kg baby = 198 mcg = 0. 4 m. L) • Add this to 50 m. L’s of solution, such as 0. 9% Na. Cl (follow own units guidelines), in a 50 m. L syringe; once the syringe is made applicable to the individual babies weight the following doses apply: • 1 m. L/hr =0. 02 mcg/kg/min or (20 nanogram/kg/min) • Dose range is 0. 01(0. 5 m. L/hr)-0. 05(2. 5 m. Ls/hr) = 10 – 50 nanogram/kg/min

18. Nursing management • • • Weight Observations Paperwork Setting up respiratory support if required (CPAP or Ventilator) Remember in duct dependent lesions oxygen usually has a detrimental effect (PDA will constrict in response to exposure to higher levels of oxygen) • Sa. O 2 in the 70% + range are OK • Gases and respiratory effort will determine need for respiratory support • Term babies, ventilated, may need infusions such as morphine or midazolam and potentially muscle relaxation (pancuronium) to ‘accept’ ventilation; they can be vigorous and difficult to manage otherwise and are at heightened risk or accidental extubation and/or ineffective ventilation

19. Reference list • www. rch. org. au/cardiology • www. bmj. com/content/343/bmj. d 6838

1. MJ • 14 yo mother, 18 yo father. Living with partner’s grandmother. • O+ve, serology negative • Seen at 15 and 21/40 • 20/40 US NAD • Presented to ED at 25/40 with PV bleeding and back pain • Arrived 1720 • Examined by O&G at 1731 • Transfer to birth suite at 1738 • Magnesium infusion commenced 1744, celestone given

2. MJ • Born at 1805 – placed in plastic zip lock back and hat put on • To resuscitaire, 2 consultants and SCN NUM present • Initial HR 60 on monitor, improved with IPPV • Successfully intubated at 11 mins (after 6 attempts) • Transferred to SCN at 20 mins • 750 g • Apgars 4, 6, 10 • Ventilated ACVG 4 m. L/kg • Bag removed as oozing thick, bloody mec into it, nappy applied • Some issues with temp control, while central lines being inserted

3. MJ • Central line insertion commenced • NETS arrived 1930 hrs, lines completed • Placed onto heated gel mattress • Caffeine loaded • Surfactant given • Transferred to Mercy • Honey moon period • Extubated day 6 to CPAP, reintubated 5 hrs later • Day 7 – abdominal distension, AXR revealed perforation • Transferred to RCH 6/9/12 DIAGNOSIS? ? ? • RIP 24/9/12

4. Management of the extreme premature infant born in a non-tertiary facility • If at all possible transport in utero!!! If not possible: CALL NETS IMMEDIATELY • Temperature management • Assisting with intubation/suction/pedicap/ taping of ET tube (protect skin with a hydrocolloid) • Ventilation • Humidity/insensible water loss • Weight/Observations (including blood pressure) • Blood glucose management • Blood gases and other tests (usually BC, FBE, CRP) • Central access (UVC’s and UAC’s): if able to do this

5. Management of the extreme premature infant born in a non-tertiary facility Fluids for central lines • Sterile technique should be used for the preparation of all fluids going into central lines • Heparinised saline for UAC • 10% Dextrose for UVC until position confirmed with XRAY • Xray will be required for ET tube placement, and for central line placement before drugs can be run through the UVC. • In a tertiary hospital parenteral nutrition would be commenced as soon as line placement confirmed as OK in a baby of this gestation/size • If unable to do central lines a peripheral line will suffice in the short term while waiting for NETS

6. Management of the extreme premature infant born in a non-tertiary facility • • Inotropes Antibiotics Caffeine loading Hep B, Vit K Communicate with Hospital coordinator Communicate with NETS/paperwork , consent Paperwork (vital: drug charts, fluid charts, birth details, child health book) • Counsel parents

7. Necrotising enterocolitis (NEC) • • Statistics Risk factors Signs and symptoms Differential diagnosis Radiographic findings Management Complications Prevention

8. NEC: Statistics • The most common gastrointestinal emergency in neonates • 90% of babies with NEC are preterm • Predominantly a disease of the VLBW infant • Most common in babies < 1000 g, or those that are both preterm and growth restricted • The incidence of NEC is inversely proportional to birthweight • Usually the age of onset is inversely proportional to gestation, ie. Smaller babies present later

9. NEC: Statistics • Approx. 50% of babies that develop NEC require surgery • The mortality rate is 20 – 40% • Of those who survive, approximately 25% develop long term sequelae • Early, or suspected, NEC is often difficult to diagnose as the clinical signs and symptoms are often non-specific, as are the radiological and laboratory findings • Babies with definite NEC should be transferred to a NICU facility • Staff working in SCN facilities need to be able to recognise suspected NEC, and be aware of management of babies transferring back who have had previous NEC

10. NEC: Risk factors • Prematurity, low birth weight • Enteral feeding (although approx. 10% of cases have never fed) • Formula feeding (6 times more likely than EBM) • Often occurs in clusters (although organisms vary) • Bowel ischaemia In term infants: polycythaemia, cardiac surgery, abdominal surgery (esp. gastroschisis, intestinal atresia) and endocrine abnormalities

11. NEC: Signs & symptoms Gastrointestinal dysfunction: • Abdominal distention • Vomitting • Bilious drainage from enteral feeding tubes • Blood in stool Systemic • Temperature instability • Apnoea’s and/or bradycardias • Lethargy • Hypotension

12. NEC: Differential diagnosis • • • Dysmotility of prematurity Septic ileus Bowel obstruction Gastroenteritis Anal fissure Cows milk protein sensitive enterocolitis

13. NEC: Radiographic findings Non specific: • Diffuse gaseous distension • Asymmetric, disorganised bowel pattern • Featureless loops • Dilated bowel loops • Bowel wall thickening • Increased peritoneal fluid

14. NEC: Management • • Nil by mouth Gastric tube on free drainage, and aspirate regularly Blood culture, +/- other bloods such as FBE, CRP Antibiotics (‘triple’, such as vancomycin, gentamycin and metronidazole – for definite) May require gut rest for 10 -14 days, therefore TPN and fluid management and analgesia Maybes: Inotropes, ventilation Frequent Xrays Surgery (in up to 50% of cases)

15. NEC: complications Surgery requiring ileostomy results in long term issues: • Require supplemental Na even when well • High risk of rapid dehydration with gastroenteritis Stricture: • 20 -30% • Most commonly in large bowel • 80% on left side • May not develop for weeks to months post-NEC • Presents with recurrent abdo distention • Surgical consultation and contrast enema required

16. NEC: Prevention • Antenatal corticosteroids • Early intervention (nil orally) for suspected NEC • Breast milk in preference to formula (donor milk bank established at MHW) • Infection control practices may limit the size of disease clusters.

17. Reference List • www. netsvic. org. au/nets/handbook

1. Baby BJ • Antenatal hx: 26 yr old, G 2 P 1, previous LUSCS (breech); bld grp O +ve, serology neg. GDM on insulin; gestational ITP (platelets on day of delivery 82) • Delivery hx (30/7/12): APH, breech until 2/52 ago, decision to perform LUSCS, no labour. Pink liquor. • Baby: cried at 20 secs, then apnoeic, IPPV for 1 min, then good respiratory effort • Apgars 9 & 9. Birth weight: 2670 g

2. Baby BJ • For admission to SCN from theatre, Issues: • Prematurity • Risk of hypoglycaemia • ? RDS • Maternal ITP • Breech until late in pregnancy Plan: • Observe resp. status, aim Sa. O 2 above 88%; BSL at 1 hr, feed if able then (dependent on resp effort); otherwise IV insertion, 10% dextrose and antibiotics

3. Baby BJ • Admitted to SCN at 1840 hrs. Hep B, Vit K given • Initial Gas: p. H: 7. 136, PCO 2: 78. 9, HCO 3: 26. 6, BE: -2, Lactate: 1. 6; TBG: 1. 7. CRP: <3, FBE: NAD (plt: 200) Plan: • IV bung inserted, 10% dextrose commenced and 2 m. L/kg bolus given (recheck TBG in 30 mins) • Hypoglycaemia resolved and not an ongoing issue • IV antibiotics commenced (Benpen 12/24, 60 mg/kg & Gent 36/24, 5 mg/kg) • Commenced CPAP of 6 cm/H 2 O; Fi. O 2: 25% at 2000 hrs • NETS notified of baby on CPAP – keep for now • CPAP increased to 7 at 2245 hrs, grunting

4. Baby BJ • Remained stable in a CPAP of 7 overnight, intermittent grunt and mild work of breathing. Fi. O 2 at 21 -23%. • CXR and bloods done 1630 hrs (CRP 4. 7, FBE NAD, plt: 167) • Reduced to CPAP of 6, in air • Parents and sibling visiting • Urine output at 1 m. L/kg/hr • Overnight: increased WOB, ? Apnoeic episode, febrile, tachypnoeic, no increase in O 2 requirement

6. XRAY interpretation (31/8/12 @ 1643 hrs) • Bilateral but diffuse reticular granular densities • Lungs do not appear hyperinflated • No pleural effusions • Heart is not enlarged • NG tube is noted, tip below L) hemidiaphragm Impression: findings would favour hilar membrane disease (RDS), with infection also in the differential

7. Baby BJ (1/7/12) • CPAP increased to 7 in the AM (Cap. G p. H: 7. 16, CO 2: 77) • Excessive handling around time gas collected, GNC, bloods etc. • CPAP reduced to 5 later in the afternoon, in air mild WOB (p. H 7. 34, p. CO 2 47) • Generalised oedema noted; Urine output increasing (3. 5) • Phototherapy commenced (SBR 158 at 40 hrs of age) • OPos group, coombs neg • Hungry, irritable at times, having small amounts of EBM as available for comfort, taking well. • Had been febrile overnight (? Environmental), CRP 3. 0

8. Baby BJ (1/7/12 cont…) • Genta level taken prior to the 2 nd dose because of concerns regarding renal function (urine output still low in the morning when dose due, significant oedema still present and Na level 135) • Genta trough level: 1. 4 so dose withheld. Nursing issues: • Weigh nappies of babies on CPAP especially in first couple of days, once diuresis evident and baby stable consider discontinuing • Be mindful of renal function when giving genta as it is metabolised in the kidneys and levels may stay high.

9. Baby BJ (1/7/12 cont. . ) • • Very unsettled 1700 hrs, crying++, not able to settle. Increased WOB noted and slight O 2 requirement (25%) Asked paed to r/v Significant deterioration (colour change, desaturation, O 2 up to 100%) at approx. 1900 hrs, following an unsettled period. Registrar in attendance, transilluminated appeared to be a pnuemothorax, CXR attended to – confirmed pnuemothorax, consultant called. • Preparation for insertion of intercostal catheter • Morphine bolus given & sucrose given • Pigtail catheter inserted by registrar at 1945 hrs

11. Xray interpretation (1/8/12 @ 1914 hrs) • Large right sided pneumothorax • Displacement of the mediastinal contents towards the left • Air space opacity in the left lung is increased likely to be due to a degree of compression from the pnuemothorax THIS BABY CLINICALLY VERY UNSTABLE, ALL HANDS ON DECK FOR ICC INSERTION!!

13. Xray interpretation (1/8/12 @ 2006 hrs) • • • R) pneumocath noted (pigtail catheter used) No residual pneumothorax Heart not enlarged, and cardiothymic contour normal NG tube seen with tip below the level of the diaphragm Bilateral air space opacities in both lungs are unchanged from previous SIGNIFICANT IMPROVEMENT INSTANTLY AS CHEST DRAIN INSERTED – AUDIBLE HISS HEARD!

14. Baby BJ • • • NETS called to retrieve, on their way Gas (p. H 7. 17, CO 2 78) 2205 hrs NETS arrived Morphine infusion commenced Still on CPAP, apnoeic episode when being examined by NETS doctor • Decision to intubate for safety for transport • Intubated/ventilated

16. Xray interpretation (2/8/12 @ 0028 hrs) • • • R) sided pleural catheter insitu Air space opacity in both lungs unchanged ET tube is seen with tip at the level of the clavicle NG tube is seen with tip below diaphragm Heart size normal No residual pneumothorax

17. Baby BJ • Gas (after intubation/ventilated): p. H: 7. 32, p. CO 2: 48, HCO 3: 25, BE: -1. 7, Lact: 2. 5 • Prepared for transport • Left at 0100 hrs Outcome: • Returned to BHS the next day, self ventilating in air, ICC out, NGT for feeds, IVT weaning. • Established feeds over the next 2 weeks and went home doing very well.

18. Pnuemothorax • • Signs & symptoms Diagnosis Nursing management Medical management

19. Signs & Symptoms • • Irritability Sudden deterioration with desaturation Increase in respiratory distress Diminished chest movements Drop in blood pressure Colour change Blood gases may reflect hypoxia, respiratory and/or metabolic acidosis

20. Signs & Symptoms & diagnosis • Unequal or decreased air entry • Displaced apex beat • Transillumination (not always reliable especially in term/oedematous infants) • CXR will confirm diagnosis (but not always a quick turn around time to have performed)

21. Management Pain relief: • Oral sucrose • Infiltration of insertion site with 1% lignocaine before preparing and draping the field • IV morphine bolus and/or infusion In an emergency can do a needle aspiration: • 21 g butterfly needle, 3 way tap, 10 m. L syringe, alcohol swab, sterile gloves • Infant supine, insert over the top of the rib in the 2 nd or 3 rd intercostal space (mid clavicular). Aspirate air into syringe, expel using 3 way tap, repeat as required until air all removed.

22. Management • Following needle aspiration an ICC will need to be inserted for ongoing management • See neonatal handbook, or own hospitals clinical practice guidelines for procedure instructions. • Under controlled circumstances effort is generally made to perform the insertion in line with the auxilla (for cosmetic reasons). • The ICC will need to be connected to a Heimlich valve or an underwater seal drainage set. • Familiarise yourself with what equipment your units have because in a high anxiety situation you don’t want to be playing guessing games on what goes where!!

23. Nursing management • Have equipment ready to attach to ICC • Keep end sterile and hand to doctor when they are ready to attacn • Set suction as required if using underwater seal drainage (until water bubbling gently in chamber – may not need suction on to achieve this). Appropriate volume of water needs to be added to chamber as indicated in instructions. • Continue with observations • Ensure pain relief is adequate • Counsel parents • Handover to NETS nurse • Copy appropriate paperwork for transfer

24. Reference • NETS handbook (pneumothorax drainage) www. netsvic. org. au/nets/handbook

1. HIE: A Case Study • Baby M was born limp, blue, and without respiratory effort at 38 wks GA to a 38 yr old, G 5 P 1 woman. • NVB after a precipitate labour • A uterine rupture was later diagnosed • Apgar scores were 1, 2 and 4 at 1, 5 and 10 mins • Resuscitated in delivery room, intubated and transferred to the NICU at the birth hospital • Initial cord p. H was 6. 7, arterial blood gas after resus showed p. H of 7. 17

2. HIE: a case study cont. . . • Neurological exam notable for dilated and unresponsive pupils, no spontaneous movements, and diminished reflexes and tone – consistent with moderate to severe encephalopathy • Seizure activity (lip smacking) commenced at 1 hr of age; confirmed on electroencephalogram (EEG/brainz monitor) • Central access was gained for fluids, medications, blood taking and continuous monitoring

3. HIE: a case study cont. . . • Criteria met to cool (respiratory depression at birth requiring intubation and continued need for ventilation, concern for placental abruption, cord p. H less than 7, clinical encephalopathy and on EEG • Cooling commenced at 4 hrs of age (criteria to achieve this by 6 hrs of age met) • Anticonvulsants given to control seizures and continued for several days

4. HIE: a case study cont. . . • Remained intubated for airway protection for several days • Fluid restricted to prevent further injury to the brain • Kidneys were affected by the hypoxic events at birth as evidenced by poor urine output and electrolyte disturbances requiring fluid restriction and electrolyte boluses • Liver enzymes were mildly elevated but there was no evidence of coagulopathy

5. HIE: a case study cont. . . • Began rewarming after 72 hrs cooled • EEG tracings on day 5 showed no evidence of seizure activity • Phenytoin ceased, phenobarbitone continued • MRI on same day showed minor changes in occipital cortex, but no significant abnormalities • Sedation lightened, extubated to room air day 6 • IV fluids liberalised and NGT feeds commenced day 7

6. HIE: a case study cont. . . • Neurological exam continued to improve – pupils became reactive, suck and gag reflexes were present and she began to move spontaneously • Normal MRI noted on day 12 • Discharged home day 15 fully suck feeding and off all anticonvulsants • Followed up 6 monthly in neurology clinic – meeting developmental milestones with no neurological deficits evident

7. • • • HIE Definition & Diagnosis Etiology & Risk Factors Incidence Pathophysiology Diagnosis Assessment Multisystem involvement Hypothermia management Nursing management Outcomes

8. Definitions • Hypoxia or Anoxia: A partial (hypoxia) or complete (anoxia) lack of oxygen in the brain or blood • Asphyxia: The state in which placental or pulmonary gas exchange is compromised or ceases altogether • Ischemia: The reduction or cessation of bloodflow to an organ which compromises both oxygen and substrate delivery to the tissue • Hypoxic-Ischemic Encephalopathy: Abnormal neurologic behavior in the neonatal period arising as a result of a hypoxic-ischemic event.

9. Etiology of HIE • Maternal: ▫ Cardiac arrest ▫ Asphyxiation ▫ Severe anaphylaxis ▫ Status epilepticus ▫ Hypovolemic shock • Uteroplacental: ▫ Placental abruption ▫ Cord prolapse ▫ Uterine rupture ▫ Hyperstimulation with oxytocic agents • Fetal: ▫ Fetomaternal hemorrhage ▫ Twin to twin transfusion ▫ Severe isoimmune hemolytic disease ▫ Cardiac arrhythmia

10. Incidence of HIE • Occurs in 1 -6 per 1000 live term births in developed countries ▫ 25% die or have multiple disabilities ▫ 4% have mild to moderate forms of cerebral palsy ▫ 10% have developmental delay (this is similar to the control population!)

11. Pathophysiology • Acute HIE leads to primary and secondary events: ▫ Primary neuronal damage: cytotoxic changes due to failure of microcirculation inhibition of energyproducing molecular processes ATPase membrane pump failure cytotoxic edema and free radical formation compromised cellular integrity ▫ Secondary neuronal damage: May extend up to 72 hours or more after the acute insult and results in an inflammatory response and cell necrosis or apoptosis (fueled by reperfusion)

12. Diagnosis • There is no clear diagnostic test for HIE • Abnormal findings on the neurologic exam in the first few days after birth is the single most useful predictor that brain insult has occurred in the perinatal period • Essential Criteria for Diagnosis of HIE: ▫ Metabolic acidosis (cord p. H <7 or base deficit of >12) ▫ Early onset of encephalopathy ▫ Multisystem organ dysfunction

13. Clinical Staging of HIE (Sarnat and Sarnat, 1976) HIE can be divided into Mild, Moderate, and Severe

14. Assessment Tools in HIE • Amplitude-integrated EEG (a. EEG) ▫ When performed early, it may reflect dysfunction rather than permanent injury ▫ Most useful in infants who have moderate to severe encephalopathy Marginally abnormal or normal a. EEG is very reassuring of good outcome Severely abnormal a. EEG in infants with moderate HIE raises the probability of death or severe disability from 25% to 75%

15. Assessment Tools in HIE • Neuroimaging ▫ Cranial ultrasound: Not the best in assessing abnormalities in term infants. Echogenicity develops gradually over days ▫ CT: Less sensitive than MRI for detecting changes in the central gray nuclei ▫ MRI: Most appropriate technique and is able to show different patterns of injury. Presence of signal abnormality in the internal capsule later in the first week has a very high predictive value for neurodevelopmental outcome

16. CNS complications • Most widely reported and best known sequelae • Major findings include: intracranial haemorrhage, cerebral infarction, cerebral oedema & gross brain swelling • Clinical manifestations: abnormal states of consciousness and tone, full or tense anterior fontanel, irritability, tremors, convulsions and poor suck

17. CNS complications • Management/monitoring: monitor systemic blood pressure, intracranial pressure (by feel of fontanel), and structural changes/damage (usually MRI) • Pharmacologically management: anticonvulsants (phenobarbitone, phenytoin); sedation, especially if ventilated and cooled (morphine, midazolam) • Prevent fluid overloading

18. Cardiovascular & Renal complications • Hypovolaemia, hypotension, shock and renal failure are the most serious sequelae of HIE • Need to monitor: urine output (weigh nappies or measure hrly if a catheter is insitu), monitor electolytes, urea & creatinine • Have to find the balance between adequate hydration for renal function but not fluid overloading (somewhere between 60 – 150 m. Ls/kg/day)

19. Cardiovascular & Renal complications • Hypovolaemia & hypotension may require management with volume expanders, blood transfusion and/or inotropes (improve cardiac contractility and cardiac output; therefore good for improving renal function as well) • If there is hypovoleamia/hypotension the bodies response is to vasoconstrict (peripheral and splanchnic), hence, there is poor perfusion to gut and kidneys. Shock response/maintain function of vital organs

20. Pulmonary complications • Provide respiratory support if required (CPAP or ventilation) • Monitor respiratory status by observation and blood gases • Treat underlying pathology, ie. Sepsis (antibiotics), meconium aspiration/PPHN (ventilation/nitric oxide), poor or no respiratory drive due to CNS complications (ventilation)

21. Metabolic & Haemological complications Monitor and manage sequelae such as: • Metabolic acidosis (ventilate and use sodium bicarbonate corrections) • Hypoglycaemia (initial infusion of 10% dextrose, but more concentrated solutions may be required if fluid restriction is required) • Hypocalcaemia (calcium corrections) • Hyponatraemia: dilutional or actual? (Fluid restrict for dilutional or replace Na if losing it through the kidneys) • Monitor blood pressure, iatrogenic blood loss (from mulitiple tests) and haematocrit level (will give you an indication of degree of haemodilution or concentration)

22. Reperfusion Injury • Reperfusion injury is the tissue damage caused when blood supply returns to the tissue after a period of ischaemia • The absence of O 2 and nutrients from blood during the ischaemic period creates a condition in which the restoration of circulation results in inflammation and oxidative damage through the induction of oxidative stress rather than the restoration of normal function • The inflammatory response is partially responsible for the damage of reperfusion injury • Restored blood flow reintroduces O 2 within cells that damages cellular proteins, DNA and the plasma membrane

23. ICE (infant cooling evaluation) trial • Conducted throughout 28 centres in Australia, New Zealand, Canada and the USA (2001 - 2007) • Cooling is started within 6 hrs of birth • Cooling can be started at the hospital of birth and continued throughout transport, by using simple equipment (gel ice packs) • The aim is to lower the brain temperature to protect it from damage • This treatment could prevent as many as 1 in 7 from dying or surviving with a significant disability

24. Management - Hypothermia • Aim for body temperature 33 – 34 degrees • Treatment continues for 72 hrs • Babies are rewarmed gradually over a 12 – 24 hr period after this time • Supportive management continues throughout treatment • EEG monitoring is performed continuously • Blood tests are performed to monitor electrolytes, liver function, renal function etc

25. Hypothermia - Mechanism of Action • Reduces cerebral metabolism, prevents edema • Decreases energy utilization • Reduces/suppresses cytotoxic amino acid accumulation and nitric oxide • Inhibits platelet-activating factor, inflammatory cascade • Suppresses free radical activity • Attenuates secondary neuronal damage • Inhibits cell death • Reduces extent of brain damage ▫ DEATH OR SEVERE DISABILITY AT 18 MONTHS OF AGE SIGNIFICANTLY REDUCED!!

26. Criteria for Hypothermia • Generally only used on term infants • Must be commenced within 6 hrs • Infants must meet at least 2 of following criteria: 1. Apgar score of 5 or less at 10 minutes 2. Mechanical ventilation or resuscitation still required at 10 mins 3. Cord or arterial p. H of <7, or base deficit of 12 or more within 60 minutes of birth • Core goal temperature of 33 – 34 degrees C for 72 hrs

27. Outcomes • The location and extent of damage, and the immediate medical management, will determine the short and long term outcomes • It is possible to have no long term complications as a result of a brain injury at birth • But complications that can occur are delayed, or failure to reach, milestones (as determined by developmental assessments); cerebral palsy; death

28. Nursing Management • Initial resuscitation • Transfer to SCN/NICU for ongoing management & observation • Baseline observations • Consider need for cooling (discuss with paediatricians/NETS) • Observe for seizure activity • Intravenous access & bloods to be taken • Medications & fluids as ordered • Measure urine output (m. Ls/kg/hr): weigh nappy, divide weight of urine by weight of baby and no. of hrs since last measured. Eg: 20 m. Ls/3. 3 kgs/4 hrs = 1. 5 m. Ls/kg/hr

Questions 1. The mother of a baby with suspected HIE inquires about the possibility of a brain insult in her infant. Of the following, the single most useful predictor of brain insult in this infant is the evidence of: A. Abnormal neurologic exam findings B. Cerebral edema on cranial US C. Elevated creatinine phosphokinase D. Hemodynamic and pulmonary imbalance E. Multisystem organ dysfunction

Questions 2. The severity of HIE can be graded as mild, moderate, or severe, using a classification proposed by Sarnat and Sarnat. Of the following, the criterion most consistent with the diagnosis of mild HIE is: A. Absence of seizures B. Low Apgar scores C. Need for assisted ventilation D. Proximal muscle weakness E. Obtunded state of consciousness

Questions 3. Several ancillary tests have been proposed to improve the prediction of long-term outcome of infants who have suffered from HIE. Of the following, the most useful and practical test for determining the prognosis of HIE is: A. Cranial ultrasound B. MRI C. EEG D. Near-infrared spectroscopy E. Somatosensory evoked potentials

References • Allan WC. The clinical spectrum and prediction of outcome in hypoxic • • • ischemic encephalopathy. Neoreviews 2002; 3; e 108 -e 115 Delivoria-Papadopoulos M, et al. Biochemical basis of hypoxic-ischemic encephalopathy. Neoreviews 2010; 11; e 184 -e 193 Casey, D. M. , Tella, N. , Turesky, R. & Labrecque, M. Therapeutic Hypothermia: Treatment for Hypoxic-Ischaemic Encephalopathy in the NICU. Neonatal Network. Nov/Dec 2011, Vol. 30, No. 6 pp 370 -380. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant, 9 th edition. 2011, p 952 -976 Marro, PJ, et al. Pharmacology review: Neuroprotective treatments for hypoxic-ischemic injury. Neoreviews 2010; 11; e 311 -e 315 Shankaran S. Neonatal encephalopathy: Treatment with hypothermia. Neoreviews 2010; 11; e 85 -e 92 Fomufod, A. K. , White, P. L Perinatal asphyxia II: Clinical management of multisystemic sequelae. Journal of the National Medical Association (1979), Vol. 71, No. 11 pg 1065 -1066

KH 18 th September • Transferred to Ballarat to establish bottle feeding • Captopril and frusemide 21 st September • All bottle feeds, NG removed 24 th September – day 39 of life • 75 g weight loss noted, lethargic • FBE WCC 20, n 11. 3, CRP 34

KH 24 th September – afternoon • Vomiting • Offensive diarrhoea +++, flecks of blood • Lethargic, pale, floppy, CRT 3 -4 s • Difficult IV access • Lactate 3. 6 • 10 m. L/kg NS bolus x 2 • Triple antibiotics commenced, NBM, NG inserted • Apnoeas • Mild abdo distension, tender ++ → morphine infusion • NETS

KH 24 th September – evening • Difficult intubation – laryngeal mask after 5 attempts at intubation • Third NS bolus – total 30 m. L/kg • Dobutamine and morphine infusions • Pancuronium • Persistently tachycardic on transfer • Loaded at left at 2240 RCH • Intubated, inotropes • No growth on faeces MCS, enterovirus PCR pending

Issues • When to intubate, when to wait for NETS • Septic, unstable neonate with cardiac condition • When to use laryngeal mask • When to start inotropes

Intubation ? When to

Inotropes

Laryngeal masks

Baby Harry

HSV in neonates