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Unit 2.1 Neo/pediatric case studies. Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP. Case study. You are called to L & D for a stat C-section for “late decells.” What is the significance of this?. The fetal heart rate is decreasing to bradycardia and not coming back up to baseline.

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Unit 2.1 Neo/pediatriccase studies

Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP


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Case study

  • You are called to L & D for a stat C-section for “late decells.” What is the significance of this?



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answer coming back up to baseline.

  • 1. gestation of baby

  • 2. mother’s prior birth history

  • 3. history of this pregnancy

  • 4. history of this labor

    • L/S ratio or phospha-tidyl-gycerol levels

    • Shake test of aminiotic fluid and ethonol


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answer labor was complicated by PROM.

  • The baby will be premature & at risk for IRDS type I

  • The baby is at risk for infection due to the PROM


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answer is 88 bpm, the baby is apnic, blue and flaccid. He is unresponsive to tactile stimulation

  • Mask bag with 100% 02 at a respiratory rate of 40-60 bpm


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Answer: is 88 bpm, the baby is apnic, blue and flaccid. He is unresponsive to tactile stimulation

  • 1 at 1 minute


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answer up, but fails to attempt to breath. At Fi02 100% by mask bagging, the Sp02 rises from 73% to 92%

  • Intubate and ventilate the infant

  • Instillation of artificial surfactant to reduce the severity of his IRDS type I


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answer # 2.5 endotracheal tube and it is taped at the 10 how do you assess this patient now?

  • 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


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answer rate of 45 bpm. The Sp02 is 93%.

  • Get an arterial blood gas:

    • The pH is 7.34 the PC02 is 35 and the Pa02 is 65 torr.


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Looking at these gases, what do you want to do? rate of 45 bpm. The Sp02 is 93%.


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answer rate of 45 bpm. The Sp02 is 93%.

  • Get a pressure ventilator set up on the following settings:

    • IMV 45

    • PIP 13

    • PEEP 5

    • Fi02 100%

    • Ti .30 to .5 seconds [closer to .3 if VSBW infant]

    • Flow rate 8- 10 lpm

  • And repeat the gas on these settings


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Answer movement and you see the Sp02 on the right hand is 95%

  • Get x-ray:

    • you see low volume lung with diffuse alveolar infiltrates and air bronchogram


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answer get an ABG on the current settings.

  • Increase the Vt by increasing the PIP from 13 to 14.

  • Increase the PEEP from 5 to 6

  • Repeat ABG


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answer get an ABG on the current settings.

  • HMD [IRDS type I] but we cannot r/o intrauterine pneumonia.


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Case study # 2 get an ABG on the current settings.

  • 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.

  • It is SVVD

  • What do you expect?


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answer get an ABG on the current settings.

  • Mom has a bad track record of infant deaths.

  • Baby is premature

  • Baby is not at risk for infection

  • Even if baby wasn’t premature, he could have immature lungs



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answer infant of a diabetic mom?

  • 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


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answer blue centrally and peripherally.

  • APGAR at 1 minute is 1.

  • Start bagging with 100% at a rate of 40-60 bpm.

  • Look at Sp02

  • Listen to breath sounds with bagging


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answer blue centrally and peripherally.

  • Get an ABG

  • Note the PIP you are bagging with

  • Place patient on PEEP

  • Repeat Sp02 in a few minutes



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Case study # 3 lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • Mom is 45 year old WF G3 P3. gestation is 38 weeks.

  • Stat C-section for late decells

  • Membranes ruptured at 1300 and the baby wasn’t delivered till 1500 the next day.

  • Mom is febrile with respiratory infection

  • What are the maternal risks, what are we worried about ?


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • 38 weeker infant is low risk for IRDS

  • Febrile and PROM puts baby at risk for intrauterine pneumonia and sepsis.

  • Late decells puts baby at risk for fetal distress.

  • What do you want to monitor?


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • APGAR’s and Silverman’s

  • Tracheal aspirate for culture and sensitivity

  • Spinal tap and blood cultures for sepsis

  • Breath sounds and pulse oximetry


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Case study # 4 lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • 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?


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • Get APGAR at 1 minute

  • Get Silverman Score

  • Listen to breath sounds

  • Get Sp02

  • Get more history on the mom


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  • Baby has an APGAR of 8 [lost points for color] lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • Baby’s Sp02 is 75% then rises to 85% within a few minutes with 30% 02 blow by

  • Silverman is 6

  • Breath sounds show diffuse crackles in the bases.

  • Mom is 28 year-old WF G1 P0


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • VS: RR 65 bpm, HR 135 bpm

  • X-Ray

    • Cardiomegally, and diffuse alveolar infiltrates and increased hilar markings. Plural effusion in the RLL

    • Blood gas:

      • pH 7. 34

      • PC02 33

      • P02 53 torr

      • Fi02 30% by hood


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  • What do you want to do? lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • 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.

  • If the Fi02 rises above 40% repeat a Blood gas to assess the need for CPAP


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • If he gets better in the next 6 hours, we can assume he has TTN

  • If he gets worse , he might have mild HMD

  • Consider cardiology consult if the cardiomegally doesn’t resolve in a few hours


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Case study # 5 lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • 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?


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • What is the mom’s history?

    • 18 year old G1 P0

  • What is the history of the pregnancy

    • No known problems

  • What is the history of the delivery?

    • Spontaneous breech birth, No PROM, but late decells in the last few minutes of labor

    • Greenish black colored amniotic fluid


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • You hope she suctioned below the cords before the baby took the first breath


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  • Why? lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1


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answer lungs from the standpoint of pulmonary surfactant so we expect this one’s L/S ratio to be less than 2:1

  • You hope she got all the meconium out of the airway because it can cause:

    • Bacterial infection

    • Chemical pneumonitis

    • Airtrapping and pneumothorax


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answer 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%.

  • 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 a chest x-ray to assess the airtrapping


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answer off the left.

  • 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:

    • Patent ductus arteriosus due to low Pa02

    • Pulmonary HTN due to low PA02

    • FO can reopen due to increased RA pressure

    • Patient will have PFC


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answer left radial is 58 torr

  • 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


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answer see any problems with this particular infant?

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


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