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CV II Exam 3 > CV Pediatric Session #1 > Flashcards

CV Pediatric Session #1 Flashcards

1
Q

A female infant born at 36 weeks gestation presented to the ED with feeding difficulties, intermittent cyanosis and apneic spells.

First Impressions?

A

Sepsis until proven otherwise!

Congenital heart disease
Inborn error of metabolism (IEM)
TORCH infections
Hypoxic ischemic encephalopathy
Intracranial bleed
Seizures
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2
Q

What kind of questions do you ask?

A 
Did mom have group B strep screen?
Fever during delivery?
Is there FH of congenital disease?
Ultrasound during pregnancy that might have shown something?
Previous kids with problems?
Relationship between parents - cousins?
Vaccinations?
What was the delivery like - aspiration, cord problems?
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3
Q

Normal pregnancy and delivery
Normal at discharge day 3

8 days later:
Ill, respiratory distress, subcostal retractions and a dusky blue color of the lips and nail beds that was intermittent. Episodic apneic spells were observed that responded to administration of O2 and stimulation. Tachycardia and tachypnea were present. Lungs revealed crackles but no regions of consolidation. No murmurs. No masses or organomegaly.

A

Still thinking sepsis

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4
Q

Neonate sepsis

A

Clinical syndrome in the neonate characterized by systemic signs of infection with bacteremia in the first month of life

Can lead to meningitis

Both gram - and +
Late and early onset

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5
Q

Early onset neonatal sepsis

A 
First week:
Usually delivery complications
Usually from genital tract
Fulminant presentation, multisystem with frequent pneumonia
3-50% die
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6
Q

Late onset neonatal sepsis

A 
7-90 days:
May not have complicated pregnancy
Can be postnatal exposure
Slow or fulminant progression
Focal meningitis frequent
2-40% die
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7
Q

Gram positive organisms

A

Group B strep (EOS and LOS)
Staphylococci aureus (LOC)
Coagulase negative staphylococcus (LOS)
Listeria monocytongenes (EOS and LOS)

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8
Q

Gram negative organisms

A

E. coli (EOS and LOS)
Haemophilus influenza
Citrobacter
(Candida albicans)

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9
Q

Clinical signs of sepsis

A

Hyperthermia > hypothermia

Wide variety of presentations

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10
Q

Clinical signs of meningitis

A 
Temp change
Lethargy
Anorexia or vomiting
Resp distress
Bulging fontanelle
Others
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11
Q

Gold standard for diagnosing sepsis

A

Culture

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12
Q

Serum biomarkers serve as:

A

Adjunct to culture based diagnosis

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13
Q

The “ideal marker” for sepsis

A

Elevates early in the infectious process
Stays elevated to allow appropriate sampling
Have well defined values that differentiate infection from other entities
A very high sensitivity and negative predictive value

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14
Q

C-reactive protein

A 
Most commonly used biomarker
Synthesized 6 hrs after exposure
Takes 24 hrs to become abnormal
Elevates with trauma and ischemia too - Not that helpful
High specificity
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15
Q

If baby has been sick 72 hrs but no CRP?

A

Sepsis is unlikely

But if CRP elevated, you can’t guarantee sepsis

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16
Q

Initial management of sepsis

A 
IV access
Cultures
Blood - cyanosis via blood gas
CSF
ABG
CXR
Glucose, electrolytes, BUN, creatinine
CRP
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17
Q

Why check kidney function in septic infant?

A

Certain antibiotics effect renal function

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18
Q

CSF showed mononuclear pleocytosis of 330 cells/µL
EEG showed multifocal epileptic potentials consistent with encephalitis
CRP 5 mg/L
Thoughts?

A

Most likely viral

Add viral encephalopathy to DDx

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19
Q

Initial treatment:
Amoxicillin, gentamicin and acyclovir
Phenobarbital
Baby continues to deteriorate with tachycardia and increasing respiratory distress requiring intubation

A

Now thinking heart and lungs

Chest xray - infiltrates, pulmonary edema
EKG - ST depression (ischemia), tachy
Echo - Reduced LV contraction, EF 20%
Troponin - Elevated

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20
Q

Enterovirus Coxsackie B3 Myocarditis

A

Confirmed with PCR

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21
Q

Enteroviral Infections in the Newborn

A

Among the most common viruses causing disease in humans
Tend to have a seasonal pattern during summer and fall
Illnesses range from a nonspecific febrile illness, mild URIs, self limiting gastroenteritis to myocarditis, hepatitis and encephalopathy

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22
Q

Enterovirus Neonatal Transmission

A

Antenatally, intrapartum and postnatally

In-utero transmission can be by transplacentally or by ascending infection

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23
Q

Common features of “Neonatal Enterovirus Sepsis”

A

Fever, irritability, poor feeding and lethargy
Non-specific rash in about half
Some have hepatomegaly

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24
Q

Treatment for the myocarditis

A

IV immunoglobulin
Decreased cardiac output and developing arrhythmias dopamine and milrinone were started
Refractory to amiodarone and electroconversion for tachyarrhythemias?
ECMO (Extracorporeal Membrane Oxygenation) was started

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25
Q

ECMO

A

External heart and lung machine to relieve work on the heart

26
Q

Illnesses acting like sepsis

A 
Bowel Obstruction
Congenital Pneumonia
Heart Failure
Hemolytic Disease
Meconium Aspiration Syndrome
Necrotizing Enterocolitis
Pericarditis, Bacterial
Pulmonary Hypoplasia
Respiratory Distress Syndrome
27
Q

Chlorampehenicol

A

Gray baby syndrome

Abdominal distension, vomiting, diarrhea, characteristic gray color, respiratory distress, hypotension, progressive shock

28
Q

Thalidomide

A

Phocomelia

Congenital abnormalities, polyneuritis, nerve damage, mental retardation

29
Q

Sulfonamide

A

Kernicterus

Displaces bilirubin from protein-binding sites, bilirubin deposits in the brain, results in encephalopathy

30
Q

Glucoronidation pathways

A

Immature in infants

31
Q

Gasping baby syndrome

A

Benzyl alcohol

Preservative

32
Q

Gastric pH in infants

A

Drops to 1-3 within 24 hours
Premature infants have immature acid secretion
Nutrition most likely responsible for initiating acid production

33
Q

Gastric emptying in infants

A

Irregular and unpredictable
Slowed/prolonged in premature - more efficient absorption
Approaches adult values within first 6-8 months
Slower with increased caloric intake
Inverse relationship between gestational age and retention

34
Q

Intramuscular drug absorption

A

Inconsistent due to differences in:
Relative muscle mass
Poor perfusion - low cardiac output states or respiratory distress syndrome
Peripheral vasomotor instability
Insufficient muscle contractions - immobile = poor absorption
Reserved for emergencies

35
Q

Drug absorption through skin directly related to

A

Degree of skin hydration

Relative absorptive area

36
Q

Drug absorption through skin indirectly related to

A

Thickness of stratum corneum

37
Q

Substantially increased percutaneous absorption

A

Underdeveloped epidermal barrier
Compromised skin integrity
Increased skin hydration
Ratio of body surface area to total body weight highest in youngest

38
Q

Drug Absorption - Rectum

A

May be important alternative site when oral agents cannot be used

Absorption can be erratic

39
Q

Total body water

A 
Fetus: 94%
Premature infants: 85%
Full-term infants: 78%
Adults: 60%
Total body water varies inversely with amount of fat tissue - babies have less fat
40
Q

Extracellular fluid volume

A

Premature infants: 50% of body weight
4-6 months: 35%
1 year: 25%
Adults: 19%

41
Q

Reduction in body water compartments

A

Use higher doses per kg of body weight

42
Q

TBW in premie

A

Less than normal

43
Q

Protein binding in infants decreased due to

A

Decreased plasma protein concentration
Lower binding capacity of protein
Decreased affinity for drug binding
Competition for certain binding sites by endogenous compounds

44
Q

Ceftriaxone

A

Displaces bilirubin

45
Q

Drug metabolism pathways in infants

A

Sulfation pathway well-developed

Glucuronidation pathway undeveloped

46
Q

Acetaminophen

A

Metabolism partially compensated by sulfation pathway

47
Q

Morphine

A

Higher serum concentrations required

Clearance quadruples between 27-40 weeks postconceptional age

48
Q

Drug elimination

A

May not fully develop for several weeks to 1 year after birth
Glomerular filtration
Tubular secretion
Tubular reabsorption

49
Q

Ampicillin

A

Inhibits PBP - inhibits bacterial cell wall synthesis
Dosing according to body weight
Bacteremia and meningitis have different dosing
Younger age, longer half life

50
Q

Gentamicin

A

Binds 30S and 50S - inhibit protein synthesis
Elimination directly related to renal function
Dosing according to weight and GA

51
Q

Cefotaxime

A

Inhibits PBP - inhibits bacterial cell wall synthesis
Dose by body weight
Bacteremia - mg/dose
Meningitis - mg/day

52
Q

Acyclovir

A

Inhibits viral DNA synthesis and viral replication

Longer half life in neonates

53
Q

Viral Myocarditis

A

Acute phase: inflammatory cell invasion of myocardium and myocardial necrosis and apoptosis
T-cell invasion: most destructive 7-14 days after inoculation
Healing phase: myocardial fibrosis; continued inflammation and persistent viremia may lead to left ventricular dysfunction and dilation

54
Q

Acute Phase Viral Myocarditis Treatment

A 
Inotropes
Afterload reduction
Mechanical ventilation
Extracorporeal membrane oxygenation (ECMO)
Immune therapy
Intravenous immunoglobulin (IVIG)
Immunosuppressive agents
55
Q

Intravenous Immunoglobulin

A

Protects recipient against infection and suppresses inflammatory and immune mediated processes
Start slow
Immediate levels, slow effect

56
Q

Pretreat IV immunoglobulin

A

Acetaminophen, diphenhydramine, glucocorticoids, hydration

57
Q

IV immunoglobulin adverse reactions

A

Chills, fever, flushing, myalgia, malaise, headache
Tachycardia, chest tightness, dyspnea, sense of doom
Thrombolic complications
Acute kidney injury

58
Q

Extracorporeal Membrane Oxygenation Neonatal indications

A 
Primary pulmonary hypertension 
Meconium aspiration syndrome
Respiratory distress syndrome
Group B Streptococcal sepsis
Asphyxia
Congenital diaphragmatic hernia
59
Q

ECMO Circuit

A

Blood siphoned, driven by right arterial pressure

Roller pump draws blood into bladder and pushes it through oxygenators and heat exchanger

60
Q

ECMO Complications

A 
Clots in circuit (19%)
Oxygenator failure
Seizures
Intracranial bleeding
Hemolysis and coagulopathy
Arrhythmias
Oliguria (within 24-48 hours)
Metabolic acidosis
61
Q

Medication Use in ECMO

A

Hemodilution - Circulating blood volume will double (blood mixing with priming solution) affecting drugs with small volumes of distribution and those that are highly protein bound

Drug binding interactions with the circuit - Adsorption and sequestration onto plastic cannula and/or silicone oxygenator

Altered renal, hepatic, and cerebral blood flow - Non-pulsatile blood flow

62
Q

ECMO and Vancomycin and Gentamicin

A

Increase doses with ECMO

CV II Exam 3 (13 decks)

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