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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 pediatric case studies

Unit 2.1 Neo/pediatriccase studies

Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP

case study
Case study
  • You are called to L & D for a stat C-section for “late decells.” What is the significance of this?
answer
answer
  • 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
slide6
This is 28 weeks gestation. Mom is 25 year old, G2 P2. The labor was complicated by PROM.
  • You are concerned because:
answer7
answer
  • The baby will be premature & at risk for IRDS type I
  • The baby is at risk for infection due to the PROM
slide8
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:
answer9
answer
  • Mask bag with 100% 02 at a respiratory rate of 40-60 bpm
answer11
Answer:
  • 1 at 1 minute
slide12
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?
answer13
answer
  • Intubate and ventilate the infant
  • Instillation of artificial surfactant to reduce the severity of his IRDS type I
slide14
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?
answer15
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.
  • Repeat APGARs in 5 minutes
slide16
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?
answer17
answer
  • Get an arterial blood gas:
    • The pH is 7.34 the PC02 is 35 and the Pa02 is 65 torr.
answer19
answer
  • 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
slide20
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?
answer21
Answer
  • Get x-ray:
    • you see low volume lung with diffuse alveolar infiltrates and air bronchogram
slide22
An umbilical artery catheter is placed and in one hour, you get an ABG on the current settings.
    • pH 7.33
    • PaC02 45
    • Pa02 48 torr
    • Sa02 88% [Sp02 is 88%]
  • What has happened & what do you suggest?
answer23
answer
  • Increase the Vt by increasing the PIP from 13 to 14.
  • Increase the PEEP from 5 to 6
  • Repeat ABG
answer25
answer
  • HMD [IRDS type I] but we cannot r/o intrauterine pneumonia.
case study 2
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
  • The baby is delivered 5 hours after labor started and membranes broke.
  • It is SVVD
  • What do you expect?
answer27
answer
  • 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
answer29
answer
  • 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
slide30
At birth, baby is flaccid, apnic with heart rate 95 bpm, blue centrally and peripherally.
  • What is the APGAR?
  • What is your intervention?
answer31
answer
  • 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
slide32
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.
  • Sp02 is 88%
  • What do you want to do?
answer33
answer
  • Get an ABG
  • Note the PIP you are bagging with
  • Place patient on PEEP
  • Repeat Sp02 in a few minutes
slide35
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
case study 3
Case study # 3
  • 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 ?
answer37
answer
  • 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?
answer38
answer
  • APGAR’s and Silverman’s
  • Tracheal aspirate for culture and sensitivity
  • Spinal tap and blood cultures for sepsis
  • Breath sounds and pulse oximetry
case study 4
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’
  • How do you assess this infant?
answer40
answer
  • Get APGAR at 1 minute
  • Get Silverman Score
  • Listen to breath sounds
  • Get Sp02
  • Get more history on the mom
slide41
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
  • Silverman is 6
  • Breath sounds show diffuse crackles in the bases.
  • Mom is 28 year-old WF G1 P0
answer43
answer
  • 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
answer45
answer
  • 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
answer47
answer
  • 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
case study 5
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.
  • What else do you need to know about this patient?
answer49
answer
  • 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
answer51
answer
  • You hope she suctioned below the cords before the baby took the first breath
answer53
answer
  • You hope she got all the meconium out of the airway because it can cause:
    • Bacterial infection
    • Chemical pneumonitis
    • Airtrapping and pneumothorax
slide54
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?
answer55
answer
  • 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
slide56
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?
answer57
answer
  • 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
slide58
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?
answer59
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
slide60
While doing what you have to do to reverse the PFC, Do you see any problems with this particular infant?
answer61
answer
  • Yes, this infant should be ventilated conservatively to prevent a tension pneumonthorax but we have to reverse the PFC.
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