Page 1098 - TNFlipTest

P64 Pediatrics
Neonatology Toronto Notes 2019
Papile Classification
Grade I: germinal matrix hemorrhage Grade II: IVH without ventricular dilatation Grade III: IVH with ventricular dilatation Grade IV: IVH with parenchymal extension
Treatment
• immediateintubationrequiredatbirth:DONOTbagmaskventilatebecauseairwillenterstomachand further compress lungs
• placelargeboreorogastrictubetodecompressbowel
• initialstabilizationandmanagementofpulmonaryhypoplasiaandPPHN,hemodynamicsupportand
surgery when stable
Hypoglycemia
Definition
• glucose<2.6mmol/L
Etiology
• decreasedcarbohydratestores:premature,SGA,RDS,maternalHTN
• endocrine:hormonaldeficiencies(GH,cortisol,epinephrine),insulinexcess(infantofdiabeticmother,
Beckwith-Wiedemann syndrome/islet cell hyperplasia), HPA axis suppression (panhypopituitarism)
• inbornerrorsofmetabolism:fattyacidoxidationdefects,galactosemia
• miscellaneous: sepsis, hypothermia, polycythemia
Clinical Findings
• signsoftennon-specificandsubtle:lethargy,poorfeeding,irritability,tremors,apnea,cyanosis,seizures
Management
• identifyandmonitorinfantsatrisk(pre-feedbloodglucosechecks)
• beginoralfeedsassoonaspossibleafterbirthandensureregularfeeds
• ifsignificantand/orsymptomatichypoglycemia,provideglucoseIVandtitrateaccordingtoblood
sugar levels
• ifpersistenthypoglycemiaornopredisposingcause,send“criticalbloodwork”duringanepisodeof
hypoglycemia: ABG, ammonia, β-hydroxybutyrate, cortisol, free fatty acids, GH, insulin, lactate, urine dipstick for ketones
Intraventricular Hemorrhage
Definition
• hemorrhageoriginatingintheperiventricularsubependymalgerminalmatrix
Epidemiology
• incidenceandseverityincreasesasGAandBWdecrease
• 50%ofIVHoccurswithin8hofbirth;90%occursbyday3
Risk Factors
• prematurity(<32wk),BW<1500g,needforvigorousresuscitationatbirth,pneumothorax,ventilated preterm infants, hemodynamic instability, RDS, chorioamnionitis, coagulopathy
Clinical Presentation
• manyinfantswithIVHareasymptomatic
• subtlesigns:alteredLOC,decreasedtoneand/oractivity,hypoventilation/apnea
• catastrophicdeterioration:mayhavebulgingfontanelle,apnea/hypoventilation,hypotension,
bradycardia, cranial nerve abnormalities, sudden drop in hematocrit, metabolic acidosis, seizures, coma
Diagnosis
• headU/Sispreferredimagingmodality
• routineheadU/Sscreeningconductedforallpreterminfants<32wkor<1500ggestationthroughout
NICU stay
• IVH graded using Papile classification
• parenchymalhemorrhagemayalsooccurintheabsenceofIVH
Management of Acute Hemorrhage
• supportivecaretomaintainbloodvolume,cerebralperfusion,andacid-basestatus • follow-upwithserialimaging
Prognosis
• outcomelargelydependentongradeofIVH,withgradesIandIIhavingarelativelyfavorableprognosis
• greatestmorbidityandmortalityisseenwithgradeIVIVHanddevelopmentofposthemorrhagic
hydrocephalus requiring ventriculoperitoneal shunt placement
• short-termsequelaeforsevereIVH:mortality,extensionofbleed,posthemorrhagichydrocephalus,
posthemorrhagic infarction, cyst formation
• possiblelong-termmajorneurologicalsequelae:CP,cognitivedeficits,motordeficits,visualandhearing
impairment