Pediatric Sessions Flashcards
36 week gestation, feeding difficulties, intermittent cyanosis, apneic spells. what ddx do you think of?
- Sepsis
- congenital heart defect
- respiratory distress syndrome
- inborn errors of metabolism (can be present from 6 hours-3 weeks)
- hypoxic/ischemic encephalopathy (compromise of O2 to the fetus)
- TORCH infections- toxoplasmosis, rubella, CMV, herpes infections
- seizures
- intracranial bleed
8-9 days after, infant appears ill, has moderate resp. distress with mild subcostal retractions, dusky blue color thats intermittent, tachycardia and tachypnea were present. auscultation of lungs shows crackles but no regions of consolidation, heart auscultation shows no murmurs. palpation of abdomen shows no masses. initial ddx and plan?
could be classic presentation of baby with neonatal sepsis
neonatal sepsis
definition: clinical syndrome in neonate characterized by systemic signs of infection with bacteriemia in first month of life
meningitis is usually a sequela of bacteremia and usually shares common cause and pathogenesis (thus need blood cultures and CSF tests)
typical organisms include both + and - organisms
two patterns of disease: early and late onset sepsis
early onset sepsis
first week of life
usually complications w/ pregnancy (mom had fever, strep screen suspect)
organism usually comes from mothers genital tract
clinical presentation: fulminant (kids get sick fast), **multisystem,
**pneumonia is frequent
mortality rate 3-50% (half of these babies could die) - must work baby up for sepsis immediately
Gram + organisms: Group B strep, listeria monocytongenes
Gram - organisms:
E. coli, H. influenza, citrobacter, candida
late onset sepsis
7-90 days out
- organism can come from mom or be post-natal environment
- presentation is slowly progressive but can be fulminant(severe/sudden) as well
- **focal meningitis is frequent
mortality rate: 2-40%
organisms:
Gram +: Group B strep, Staph aureus, coagulase negative staph, listeria monocytongenes (neonatal meningitis)
Gram - organisms:
E. coli, H. influenza, citrobacter, candida
+ organisms associated with bacterial sepsis
Group B strep - EOS/LOS
Staph aureus - LOS
Coagulase neg. staph - LOS
Listeria monocytogenes - LOS/EOS (hx of mom ingesting cheese and dairy products and canteloupe)
gram- associated with group B strep
E. coli (EOS and LOS)
Haemophilus influenza
Citrobacter
Candida albicans
what are clinical signs of bacterial sepsis
1/2 have hyperthermia - fever
15% have decreased temp
33% have resp. distress
apnea, cyanosis, jaundice, hepatomegaly, lethargy, irritability, anorexia, vomiting abdominal distension
clinical signs of bacterial meningitis?
62% have hypothermia/fever
50% with lethargy/irritability 48% anorexia and vomiting 41% resp. distress 35% bulging or full fontanelle 31% siezures 28% jaundice 16% nuchal rigidity diarrhea
how to make ddx of neonatal sepsis?
blood culture is gold standard
serum biomarkers can serve as adjunct to culture based ddx
Ideal marker:
- elevates early in infectious process
- stays elevated while sick
- has well defined values that differentiate infection from other entities
- a very high sensitivity and negative predictive value
CRP
most commonly used biomarker
synthesized 7 hours after exposure/infectious process
takes up to 24 hours after onset of infection to become abnormal
is also elevated w/ trauma and ischemia
good indicator for neonatal sepsis? probably not, so many resons it could be high
CRP does have high specificity - meaning if you have baby thats been sick for 48 hours and run CRP and its negative, it rules out neonatal sepsis
management of sepsis?
IV access, take blood cultures, CSF cultures, ABG, CXR, glucose electrolytes, BUN, CR, CRP levels
lab results of case: CSF shows mononuclear pleocytosis of 330 cells. EEG shows multifocal epileptic potentials consistent with encephalitis. CRP 5 (normal is less than 10)
mononuclear pleocytosis - significant for viral infection
Pleocytosis is an increased cell count {Gk. pleion more}, particularly an increase in white blood cell (WBC) count, in a bodily fluid, such as cerebrospinal fluid (CSF).[1] It is often defined specifically as an increased WBC count in CSF.[2]
empirical tx with amoxicillin/gent/acyclovir is started. despite antibiotics the baby continues to deteriorate with tachycardia and respiratory distress. new studies needed?
seems to have viral encephalitis
CXR shows pulmonary edema and infiltrates
EKG: shows ST depression and tachycardia (heart is becoming is ischmic) in V1-V4
Echo: shows normal anatomy with severely reduced LV EF of 20%
troponin levels are very high with newborn (10.2, should be less than 0.04)
this probably viral
final ddx of baby?
enterovirus coxsackie B3 myocarditis - this is one of the most common viruses causing disease in humans with 10-15 million infections yearly in US
infections occurs in summer and fall, and range from nonspecific febrile illness, mild URIs, myocarditis, hepatitis and encephalopathy.
transmission to neonate is antenatally, intrapartum and postnatally - it can occur in many different ways
clinical features of enterovirus infection?
wide spectrum of signs ranging from nonspecific febrile illness to fatal multisystem disease called “Neonatal Enterovirus Sepsis”
most common presents: fever, irritability, poor feeding and lethargy
hepatomegally may be present but splenomegaly is rare - half show evidence of hepatitis
nonspecific rash seen on half of infants
tx for neonatal enterovirus sepsis
VI IgG give
dopamine and milrinone started for decreased CO and developed arr.
extracorporeal membrane oxygen (ECMO) was started - heart and lung machine used for babies - allows for heart to be rested and sometimes the heart will improve
what does post-mortem exam show of viral myocarditis?
inflamm. infiltrate lymphocytes and extensive necrosis of myocardium - virus got into the heart and resulted in a myocarditis that was fatal
often these children need heart transplants
pediatric patients
<18 y/o
premature
<37 y/o
chlorampehenicol
- antibiotic that is strong and unable to be metabolized in children
“gray baby syndrome” - see abndominal distension, vomiting, diarrhea, characteristic gray color, resp. distress, hypotension, progressive shock
thalidomide
“phocomelia” - used for nausea in pregnant women
- inhibition of DNA synthesis/angiogenesis
saw congenital abnormalities, polynueuritis, nerve damage, mental retardation
Sulfonamide
“kernicterus”
- displaces billirubin from protein-binding sites on albumin, this bilirubin deposits in brain
- due to immature glucoronidation pathways
benzyl alcohol
used in many IV drips
- this has resulted in “caspean baby syndrome” - resp distress, metabolic problems,
drug absorption in GI tract
Gastric pH
- full term infant: pH 6-8 at birth
- pH drops to 1-3 within 24 hours
- premature infants have immature acid secretion adn pH remains elevated
- extrauterine factors most likely responsible for initiating acid production (nutrition)
Gastric emptying in neonatl period?
irregular and unpredictable
- gastric emptying is slowed/prolonged in premature infants, leads to prolonged contact time, increased absorption, can also delay absorption if drug is absorbed further down intestine
- this approaches adult values in first 6-8 months of life
- there is inverse relationship to gestation age and gastric retention: younger baby = increased gastric retention
IM drug absorption?
- *IM absorption is inconsistent and relative on mm. mass
- can see poor perfusion in neonates due to low CO states or RDS
- peripheral vasomotor instability and insufficient mm. contractions cause problem
- sick immobile neonates may show reduced absorption rates
- IM is reserved for emergencies and when IV sites aren’t accessible
drug absorption from skin?
- directly related to degree of skin hydration and absorptive area
- inversely related to thickness of stratum corneum
- see substantially increased percutaneous due to underdeveloped epidermal barrier, compromised skin integrity, increased skin hydration,
rectal absorption? finish slide
used if pt. has nausea, vomiting, seizure activity, preparation of surgery
there is erratic absorption depending on formula/retention time
why is neonatal protein binding decreased?
- decreased plasma protein concentration (albumin reaches adult values around 10 mos)
- lower binding capacity of protein
- decreased affinity for drug binding: affinity of albumin for acidic drugs increases from birth to early infancy
- compettion for certain binding sites by endogenous compounds (high serum FFA’s, bilirubin)
how long do you tx for meningitis?
14 days with ampicillin
maternal lupus
congenital heart block
diaphoresis (sweating) and tachypnea with feeding, cyanosis, FTT
think cardiac when you hear this
acrocyanosis
acrocyanosis: when all babies are born they will have a small amount of cyanosis of fingers and toes
is wide and fixed split S2 abnormal?
NO.
IV has a thrill
III doesn’t
what is innocent vs. suspicious murmur?
low pitched, non turbulent, not high velocity, changes with position
suspicious: high pitched, harsh, holocystolic, fixed
Still’s murmur?
low pitched sound heard at lower left sternal area described as musical. (“whistling”) Can change with positional changes, no clicks are present. - this is innocent
venous hum
low-pitched continuous murmurs made by blood returning from great vv. to heart - this is innocent
pulmonary flow murmur
“benign peripheral pulmonary stenosis” - high pitched and best heart in upper left sternal border - this is innocent
differneces b/w upper and lower pulses
think coarctation of aorta
how are EKG’s different in peds?
right ventricular dominance and RAD, and different interval lengths
know four pediatric shunts
study it
down syndrome
endocardial cushion defect, VSD
turner synrdrome
XO, short webbed neck, coarcation, AS, ASD
noonan syndrome
like a male turners, has same phenotypic features, PS, ASD< AVSD< coarc, HCM
FAS
VSD, PDA, AS, TOF
endocardial cushion defects
like you have just one ventricle
transposition of great vessels = TGV
associated with severe cyanosis in the first HOURS after birth - this is most likely ddx in severely cyanotic neonate in just a few hours old
- need surgical switch
interesting heart shapes?
Egg shaped heart = TGA
snowman = TAPVR- mostly pulmonary congestion, pulmonary vv. are returniing to weird places like SVC
reverse figure 3 = coarctation of aorta
disorder of myocardium?
often VIRAL: coxsackie, echovirus, polio, mumps, measels, rubella
ddx: by ST changes - depresstion or elevation
Labwork: PCR: used to find the viral genome in myocardial cells
tx: supportive and IVIG
Kawasaki diesase
- Fever for Five days!
and
at least four of following: conjunctival injection, strawberry tongue, cervical - lymphadenopathy, swelling of hands and feet/rash
15-20% develop coronary artery aneurysms, and are followed due to problems with stenosis chronically
aspirin is given to kids as tx
endocarditis
sticky valves (abnormal valves) = wimpy bugs can stick to them
smooth valves = sticky bugs (i.e staph aureus) - bad viruses will stick to healthy valves
sports PE screening?
family h/o early sudden death - cardiac, seizure, one car accident
murmurs (HCM)
Marfan’s stigmata
undiagnosed coarc - palpate radial and femoral pulses at same time
PE findings consistent with cardiac disease
def of neonate
1 day to one month
infants
one month - one year
children
1-11 years
neonatal drug distribution?
total body water/ECF volume is higher in premature infants than full-term infants, than children, than adults
thus must use higher doses per kg of body weight in younger children to acheive comparable plasma and tissue concentrations
Drug metabolism in infants? Acetaminophen? Morphine?
Pathway maturation
Infants: sulfation pathway well-developed, glucuronidation pathway undeveloped
- Acetaminophen: metabolism partially compensated by sulfation pathway
- Morphine: higher serum concentrations required; however, clearance quadruples between 27-40 weeks postconceptional age
Drug elimination pathway is not fully developed for several weeks to 1 year after birth
common causes of neonatal sepsis?
Group B strep (GBS)
E. Coli
Listeria monocytogenes
use ampicillin, gentamicin, third generation cephalosporin most often used
ampicillin
MOA: inhibits cell wall synth
- half life is longer in younger children
- dosing due to age
for GBS bacteremia: dosing based on body weight
For meningitis: treat at least 14 days
tx: neonatal sepsis
gentamicin
MOA: inhibits bacterial protein synth by binding 30S and 50S ribosomal subunits and causing defective cell memrane
Dosing is due to age and weight
tx: neonatal sepsis
cefotaxime
MOA: inhibits bacterial cell wall synth- leads to bacterial cell wall lysis
viral myocarditis in children?
implicated in up to 12% of SCD in adolescents/YA’s
Pathophys:
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
tx of acute phase of viral myocarditis?
- inotropes, afterload reduction, mech. vent, ECMO, immune therapy
- intravenous igG
adverse effects of IV IgG?
Chills, fever, flushing, myalgia, malaise, headache
Tachycardia, chest tightness, dyspnea, sense of doom
Thrombolic complications
Acute kidney injury
ECMO
Extracorporeal Membrane OxygenationProlonged cardio-pulmonary bypass (3-10 days)
Supports patients with life-threatening respiratory or cardiac failure
Neonatal indications: Primary pulmonary hypertension Meconium aspiration syndrome Respiratory distress syndrome Group B Streptococcal sepsis Asphyxia Congenital diaphragmatic hernia
complications: Clots in circuit (19%) Oxygenator failure Seizures Intracranial bleeding Hemolysis and coagulopathy Arrhythmias Oliguria (within 24-48 hours) Metabolic acidosis
