volume 3 Flashcards
Name 5 risk factors for neonatal hypoglycaemia
- small for gestational age
- large for gestational age (90th % (controversy if non IDM LGA infants truly at risk)
- IDM
- preterm infants <37 week
Can also get from : perinatal asphyxia, inborn metabolic or endocrine conditions
Infant is identified as at risk (based on above) when should you check the glucose?
start at 2 hours of age (after an initial feed)
**for symptomatic infant, check at any point
How long should you continue checking the sugar for infants at risk (as mentioned above)
for the at risk period
- for IDM and LGA - 12 hours
- for small GA and preterm - 36 hours
delay in processing a blood sample, what do you expect will happen to the glucose level?
will get lower
we rely a lot on point of care
new POC likely better
don’t rely to much on the oleo ones
exam answer is trust the lab
symptoms of hypoglycaemia
jittery tremor seizure cyanosis apnea/tachypnea limp high pitched or weak cry trouble feeding eye rolling can have sweating, pallor, hypothermia and cardiac arrest and failure
SGA baby feeds at 2 hours, glucose is 1.7, what to do? no symptoms
1) IV dextrose
2) feed again
IV dextrose
IDM baby feeds at 2 hours, glucose is 1.9, fed again, continues to be 1.9, what to do?
IV dextrose
since subsequent still < 2.0
symptomatic baby with glucose 2.5 what to do
feed and repeat
treat asap
if symptomatic and <2.6, treat asap
stable baby who is SGA but having repeated glucose of 2.4, what to do?
IV therapy since consistently <2.6
What to start glucose at?
IV D10 at tfi 80 cc/kg/day (GIR 5.5 mg/kg/min)
increase up to IV D12.5 at 100 (GIR 10) at this point should consult speciality, consider glucagon
how many babies with brachial plexus palsy will have residual deficits?
20-30% (before used to say that 90% will recover completely)
who should you refer to multi D team with brachial plexus palsy
if incomplete recovery by 3-4 weeks, full recovery unlikely should refer to multi D team
who many will recover within 1st month of life from brachial plexus injury?
75%, 25% will have permanent impairment and disability
favorable prognostic signs for neonatal brachial plexus palsy?
onset of recover within 2 weeks
involvement of only proximal upper extremity
Brachial Plexus Palsy C5-7
Erb (remember Erb 57)
Erb is a waiter
Brachial Plexus Palsy C8-T1
Klumpke Klumpke has a claw
When will you recover from brachial plexus injury?
75%, 25% have disability
When to refer ?
> 1 month of symptoms
What increases risk of brachial plexus injury?
fat baby
diabetes
shoulder dystocia
instrumentation
Benefits of Surfactant
- decreases pneumothorax
- reduce mortality
- decrease ventilation
- decrease pneumo and interstitial emphysema
- better neurodevelopment
get to max D12.5 at 120, but still glucose low, what to do
- endo
- pharm intervention (IV glucagon, hydrocortisone, diazoxide, octreotide)
- Critical sample
How often does HIE happen
1/1000-6/1000, often without warning can happen in community hospitals
What are some clinical features of HIE
- CNS injury - with or without other involvement, severe will always involve other organs, moderate can be isolated
- Renal (42%) oliguria/anuria/ATN, renal failure
- Pulmonary (26%) : RDS, surfactant dysfunction, PPHN
- GI (29%): paralytic ileus or delayed, NEC
- Hepatic - increased ammonia, gill, GGT, decreased clotting factors at 3-4 days
- Heme - thrombocytopenia
- Metabolic: acidosis (lactate), hypoglycemia (hyperinsulinism), hypocalcemia (increased phosphate load, correction of metabolic acidosis
- CVS: shock, hypotension, ventricular dysfunction, CHF
Who should get cooled for HIE
- moderate to severe HIE - standard of care
- term and late preterm greater or equal to 36 weeks
- less than 6 hours of age
- meet criteria A AND B (see below)
what is the therapeutic window for interventions in HIE?
phase 1: reduction blood flow and O2 supply, gal in ATP, fall in Na/K pump, depolarization etc
LATEN period - after resuscitation and repercussion 6-12 hours - this the window for intervention to help reduce cell death
What are the criteria for cooling?
criteria A (need 2) : apgar16 in gases within 1 hour of birth criteria B: moderate or severe (sarnat II or III) demonstrate by seizures or at least one sign in 3 categories in the table in the statement
if they meet the criteria then should offer cooling
can consider doing EEG at 5.5 hours to help see if there are seizures
Contraindications to cooling
- IC bleeding/severe head trauma
- > 6 hours of age or <36 hours gestation (no evidence)
Initiation of cooling for infants with very severe encephalopathy, congenital anomalies or abnormal chromosomes is best performed in consultation with a tertiary centre.
Which type of cooling is best?
no difference in outcomes for both head and total body cooling
What is total body cooling vs selective head cooling
- head - cooling caps, fontanelle < 30 C, rectal temp 34 +/- 0.5 , expensive, lots of work, can cause scalp edema, skin breakdown
- total body - to temp 34 +/- 0.5 C, cheaper, can do EEGs, easier to do - can do it with passive cooling, cool packs and/or cooling blankets
What temperature should you target for cooling?
34 +/- 0.5 C
Sarnat staging - what stage of HIE most likely to have seizures?
a) mild
b) moderate
c) severe
moderate - uncommon in severe (and none in mild)
level of consciousness is hyper alert, what stage of HIE?
mild - is hyperalert (vs lethargic in moderate and coma in severe)
Pupils are small but reactive in which stage of HIE?
small in moderate
(large in stage 1, non reactive in 3)
remember that mild is sympathetic (so big pupils, tachy, normal RR, not may secretions)
moderate is parasympathetic (i.e. starting to give up) - small pupils, brady, slow breathing, lots of secretions
severe is nada
strong distal flexion, what stage of HIE?
moderate
in mild you have weak distal flexion, and in severe decerebrate
How long should cooling last?
optimal unknown - most use 48-72 hours in the studies, 72 hours most common
How quickly should you rewarm a baby after cooling them?
0.5 every 2 hours in most
don’t want to go too fast
can get worsening of seizures and encephalopathy
What are some side effects of cooling?
overall pretty safe - no serious SEs 1. hypotension 2. arrythmias 3. thrombocytopenia 4. edema have been described
Why is cooling unsafe in preterm infant?
associated with increased mortality
no evidence in <36 weeks
doing studies in late preterm now
Why do we do cooling for IE?
because it reduces mortality and negative neurodevelopment consequences in kids with moderate HIE
severe is less likely to benefit from treatment
should do it either in a level 3 NICU or after talking to a level 3 NICU
