早产儿常见之问题.ppt

早產兒常見之問題(1),IVH(intraventricularhemorrhage):腦室內出血PVL(periventricularleukomalacia):白質軟化症ROP(retinopathyofprematurity):早產兒視網膜病變RDS(respiratorydistresssyndrome):呼吸窘迫症候群,早產兒常見之問題(2),BPD(bronchopulmonarydysplasia):支氣管肺發育不全NEC(necrotizingenterocolitis):壞死性腸炎PDA(patentductusarteriosus):開放性動脈導管,Gestationalageestimationandbirthweightclassification,InfantareclassifiedbyGAasPreterm(37weeks)Term(37-416/7weeks)Postterm(42weeksormore)BirthweightclassificationNormalbirthweight(NBW):2500gmormoreLowbirthweight(LBW):2500gmVerylowbirthweight(VLBW):ligmentumarteriosumBothPGE2andPGI2relaxtheductusarteriosus,Incidence,Prematurity:inversewithGA,PDAisfoundinabout45%ofinfantunder1750gand80%ininfantsweightingfallinpulmonaryvascularresistanceandariseinsystemicresistanceifPDAopenedlefttorightshunt(+)-resultinincreasedpulmonarybloodflow,leftventricularvolumeoverload,increasedleftventricularend-diastolicvolumeandpressure-CHF,Pathophysiology,Renal,mesentericandcerebralbloodflowdecreasedduetoductalstealThesewithmoderateandlargeductsarepronetothedevelopmentofpulmonaryvascularobstructivediseaseby1yearofageorbeyondPreterminfantmaydevelopCHFearlierbecauseofincompletedevelopmentofthemedialmusculatureinthesmallpulmonaryarteriolesAmongthosewithRDS,theymaybeainitialperiodofimprovementasthepulmonarystatusimproves,Clinicalfindings(Terminfants),Pulmonaryvascularresistancedeterminestheclinicalmanifestations:AcontinuousmurmurisheardinfrequentlyLargePDAhas1.boundingperipheralpulsepressure,2.widepulsepressure(differencebetweensystolicanddiastolicpressure)3.hyperactiveprecordium:duetoelevatedstrokevolume,Clinicalfindings(Terminfants),4.HypotensionparticularintheseofELBW5.HeartfailureinlargePDAdoesntdevelopuntil3to6weeksofageAssociatedwithpulmonarydisease,leftheartobstructivelesionandcoarctationofaorta,pulmonaryresistancemaybehigh-righttoleftshunt-nomurmur,Clinicalfindings(preterminfants),1.Thesameclinicalsignastermbaby2.However,manypretermbabywithlargePDAhavenomurmur3.Mostwillhaveanincreasedpressure,Diagnosis,Chestxray:cardiacenlargement,pulmonaryplethora,aprominentmainpulmonaryarteryandleftatrialenlargementEKG:leftventricularhypertrophy,leftatrialhypertrophyEchocardiography:1.M-mode:normalLA:Aaratioininfantsisbetween0.8-1.0,Aratio1.2suggestsleftatrialenlargement(intheabsenceofleftventricularfailureorvolumeoverload)2.2-D:PDA,Treatment,Terminfants:NoevidenceofcardiovascularembarrassmentshouldbefollowedandcatheterclosureorthoracoscopicorsurgicaldiversionDigoxinanddiureticsforPDAwithCHF,Preterminfants,1.Ventilatorsupportandfluidrestriction2.Indomethacintreatmentproducesclosurein85%ofpatients3.Prophylacticadministrationofindomethacinearlyafterbirthinveryprematureinfants(1250g)decreasedtheincidenceofPDA,CHF,IVHandpossiblymortality-butnotroutineduetotheriskofleukomalacia,decreasedrenalfunction,plateletfunctionandNEC,Preterminfants,4.Ibuprofen(10mg/kg)mayhavefewersideeffect.ArchivesofDiseaseinChildhood:Fetal&NeonatalEdition.76(3):F179-84,1997May.(ibuprofendidnotsignificantlyreducemesentericandrenalbloodflowvelocity.)JournalofPediatrics.135(6):733-8,1999Dec.5.Bloodtransfusioninanemicpretermbabydiminishestheleftventriclevolumeoverloadandhastenductusclosurebyincreasingarterialoxygencontent,Preterminfants,Earlyindomethacintreatment(inprematureinfantswithrespiratorydistresssyndrome)improvesPDAclosurebutisassociatedwithincreasedrenalsideeffectsandmoreseverecomplicationsandhasnorespiratoryadvantageoverlateindomethacinadministrationinventilated,surfactant-treated,preterminfants32weeksgestationalage.(JournalofPediatrics.138(2):205-11,2001Feb.),PDA,Coilocclusionisasafeandeffectivemethodofpercutaneousclosureofsmalltomoderate-size(minimumdiameter1.7mg/dl2.Frankrenalorgastrointestinalbleedingorgeneralizedcoagulopathy3.NEC4.sepsis,Necrotizingenterocolitis(NEC),Necrotizingenterocolitis,1.Definition2.Incidence3.Pathology&Pathogenesis4.Clinicalmanifestations5.Diagnosis6.Management7.Complication,Definition,Themostcommonlife-threateningemergencyofthegastrointestinaltractinthenewbornstage.Anacquiredneonataldisordercharacterizedbyvariousdegreesofmucosalortransmuralnecrosisoftheintestine.,Incidence,Decreasedbirthweight&gestationalageincidence&fatilityRareinterminfants.Overallmortality2040%.NeonatalICU15%Noassociationwithorrace.Occuressporadicallyorinepidemicclusters.Mostinvolvedthedistalpartoftheileumandtheproximalsegmentofcolon.,Pathology&Pathogenesis(1),Cause:remainsunclearbutismultifactorial.Noprovencausehasbeenestabilished.ThegreatestriskPrematureInteractionsbetweenmucosalinjury(ischemia,infection,inflammation)andthehostsresponsetotheinjury(circulatory,immunologic,inflammatory),Pathology&Pathogenesis(2),Clusteringofthecasesinfectiousagent(E.Coli.,Klebisella,Enterobacter,Salmonella,Coronavirus,Rotavirus,Enterovirus)Nopathogenisidentified.Rarelyoccuresbeforeenteralfeeding.Muchlesscommonininfantsfedhumanmilk.Triadintestinalischemia,oralfeeding,pathogenicorganisms,InitialischemicortoxicmucosaldamageLossofmucosalintegrityEnteralfeedings+BacterialproliferationNecrosisoftheintestineGasaccumulationinthesubmucosaofbowelwall(penumatosisintestinalis)TransmuralnecrosisorgangranePerforation,Sepsis,Death,Clinicalmanifestations,Avarietyofsignsandsymptomsandmaybeonsetinsidiouslyorsuddenly.Usuallyoccursinthefirst2weeks.Ageofonsetisinverselyrelatedetothegestationalage(VLBW3month).Firstsigns:abdominaldistensionwithgastricretention.25%bloodystoolProgressmaybeberapid,butunusuallytoprogressfrommildtosevereafter72hr.,Signsandsymptomsassociatedwithnecrotizingenterocolitis,GastrointestinalAbdominaldistentionAbdominaltendernessFeedingintoleranceDelayedgastricemptyingVomittingOccult/grossbloodstoolChangeinstoolpattern/diarrheaAbdominalmassErythemaofabdominalwall,SystemicLethargyApnea/respiratorydistressTemperatureinstabilityAcidosisGlucoseinstabilityPoorperfusion/shockDICPositiveresultsofbloodculture,Diagnosis,Averyhighindexofsuspicionintreatinginfantsatriskisessential.Clinicaltriad:Feedingintolerance,abdominaldistention,grosslybloodystools.Labstudies:CBC,electrolytes,bloodculture,stoolscreening,stoolculture,Radiologicstudies:1.X-rayofabdomen:Pneumomatosisintestinalis(50-75%)Portalvenousgas2.Hepaticultrasonography,KUBdemonstratingabdominaldistention,hepaticportalvenousgas(arrow),andbubblyappearanceofpneumatosisintestinalis(arrowhead).ThelattertwosignsarepathognomonicforNEC.,Intestinalperforation.Cross-tableabdominalroentgenograminapatientwithNECdemonstratingmarkeddistentionandmassivepneumoperitoneumasevidentbythefreeairbelowtheanteriorabdominalwall.,Management,BasicNECprotocol:1.Nothingbymouth(NPO)2.Useofanasogastrictube3.Antibiotics4.Monitoringofvitalsigns&abdominalcircumference5.Removaloftheumbilicalcatheter6.Monitoringoffluidintakeandoutput7.Monitoringforgastrointestinalbleeding8.Laboratorymonitoring9.Septicworkup10.Radiologicstudies,ManagementbyStages,Classifiedbyclinicalsyndrome(1986WalshandKliegman),StageI:SuspectedNECSystemic:Nonspecific,apnea,bradycardia,andtemperatureinstabilityGastrointestinal:IncreasedgastricresidualsOccultbloodstoolRadiographic:NormalornonspecificTreatment:NPOwithantibioticsfor3days,StageIIAMildNEC,Systemic:Nonspecific,similartostage1Gastrointestinal:AbsentbowelsoundsandGrossbloodstools.Radiographic:Ileuswithdilatedloops,focalareasofpneumatosisintestinalisTreatment:NPOwithantibioticsfor10-14days,StageIIBModerateNEC,Systemic:MildmetabolicacidosisandmildthrombocytopeniaGastrointestinal:Tenderness,abdomianlwalledema,palpablemassRadiographic:Extensivepneumatosis,portalvenousgas,earlyascitesTreatment:SimilartostageIIB,StageIIIAAdvancedNEC,Systemic:Hypotension,bradycardia,respiratoryfailure,coagulopathyseveremetabolicacidosisGastrointestinal:Spreadingedema,erythemaindurationoftheabdomenRadiographic:ProminentascitesTreatment:paracentesis,fluidresuscitation,inotropicagentsupport,ventilatorsupport,.,StageIIIBAdvancedNEC,Systemic:Deterioratingvitalsigns,shock,electrolyteimbalanceGastrointestinal:PerforationofthebowelRadiographic:PerforationofthebowelTreatment:Surgicalmanagement,Surgicalmanagement,Indicationforoperation:1.Evidenceofintestinalperforation2.Aspersistent,fixedsenileloop3.Erythemaoftheabdominalwall4.Apalpablemass5.BrownparacentesisfluidwithorganismsonGramstain6.Failuretoresponsetomedicaltreatment.,Prognosis,Pneumatosisintestinalis:20%failsinmedicalmanagement,9-25%die.About75%ofallpatientsurvival50%developalong-termcomplicationThe2mostcommoncomplicationsareintestinalstrictureandshort-gutsyndrome.,Complication(1),Intestinalstricture:1.Occurin10%ofpatirnts.2.Diagnosedbybariumenema3.S/S:feedingintoleranceandbowelobstructionoccur2-3weeksafterrecoveryfromtheinitialevent4.Tx.:Resectionoftheaffectedportion.,Complication(2),Short-gutsyndrome:1.Mostinpa