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NICU MORTALITY

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NICU Mortality. Objectives. Emphasize the importance of a dequate communication between medical teams, regular and proper evaluation of adequacy of resuscitation Present the Therapeutic Hypothermia Protocol according to the Journal of Clinical Neonatology. R.V. Term B aby Boy NSD - PowerPoint PPT Presentation

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Page 1: NICU Mortality

NICU MORTALITY

Page 2: NICU Mortality

Objectives

• Emphasize the importance of adequate communication between medical teams, regular and proper evaluation of adequacy of resuscitation

• Present the Therapeutic Hypothermia Protocol according to the Journal of Clinical Neonatology

Page 3: NICU Mortality

R.V.

• Term Baby Boy• NSD • 35 y.o. G2P2 (2002) • 39 3/7 weeks AOG• Anthropometrics:– BW 3120g, BL 53cm, HC 34cm, CC 31cm, AC 30cm– AGA

• Apgar score: 0, 0, 1, 1, 1

Page 4: NICU Mortality

Maternal History

• Regular prenatal check-up• Regular intake of multivitamins• Ultrasound – unremarkable • Congenital anomaly scan – normal• Normal OGCT• No BP elevations• CBC and UA upon admission – normal

Page 5: NICU Mortality

Past Medical History

• No hypertension, no DM

Family History• (+) hypertension, DM, heart disease, colon CA

Personal/Social History• Occasional alcoholic beverage drinker,

nonsmoker, no use of illicit drugs

Page 6: NICU Mortality

OB History

• G1 – 2009 – NSD, full term male, no fetomaternal complications

• G2 – present pregnancy

Page 7: NICU Mortality

Admitting CTG: 3hrs 30mins prior to delivery

Baseline 130 - 135bpm, with accelerations, no decelerations, good fetal movement, strong contractions every 8 mins

Page 8: NICU Mortality

After CEA: 3hrs prior to delivery

Baseline 140 bpm, with accelerations, no decelerations, good fetal movement, strong contractions every 8 mins

Page 9: NICU Mortality

After AROM: 2hrs 30mins prior to delivery

Baseline 135 to 140 bpm, moderate variability, with accelerations, with variable decelerations as low as 60 bpm with slow recovery, with moderate to strong uterine contractions every 3-4 minutes

Page 10: NICU Mortality

1hr and 30mins prior to delivery

Baseline 135 to 140 bpm, moderate variability, with accelerations, with variable decelerations as low as 70 bpm with slow recovery, with moderate to strong uterine contractions every 2-3 minutes

Page 11: NICU Mortality

Prior to transfer to DR: 1hr prior to delivery

Baseline 130-135 bpm, moderate variability, no accelerations, with variable decelerations as low as 60 bpm with slow recovery, with moderate to strong uterine contractions every 3-4 minutes

Page 12: NICU Mortality

FHT tracing at DR (supine)

Change in baseline 120 bpm, moderate variability, no accelerations, with variable decelerations as low as 50 bpm with slow recovery

Page 13: NICU Mortality

Tracing at DR (Left lateral decub): 40mins prior to delivery

Maternal heart tone

Page 14: NICU Mortality
Page 15: NICU Mortality

APGAR Score

0

00000

0

00

00

0

000

0

1

101

001

00

000

1 1

39 2/7

Page 16: NICU Mortality

NICU Transfer

Page 17: NICU Mortality

At the NICU

• Pale, unresponsive • BP not appreciated, HR 180, on bag-tube ventilation,

T 34C• No dysmorphic features• Pupils 8-9mm dilated, not reactive to light• No spontaneous breathing, Equal chest rise, good air

entry both lungs• Regular cardiac rhythm, no murmur appreciated• Soft abdomen• Poor pulses, CRT prolonged

Page 18: NICU Mortality

Severe Hypoxic-Ischemic Encephalopathy, post cardiopulmonary arrest

Initial assessment

Page 19: NICU Mortality

Problems• Asphyxia• Mixed Metabolic and Respiratory Acidosis, Intractable

15 mins of life VBG (Bag tube vent at 10lpm)

pH 6.604

C02 61.2

PO2 114.5

HCO3 6.1

BE -30

O2 sat 82.9%

Mixed metabolic and respiratory acidosis

Correction with NaHCO3Therapeutic Hypothermia

VBG (MV settings: Fi02 100, iT 0.5 FR 10 PIP 26 PEEP 50 RR 50)

6.52

95.6

79

7.8

-30

60%

Mixed met and resp acidosis

Hooked to MV

Lactate (4.5-19.82

mg/dL)

223.2 mg/dL

Page 20: NICU Mortality

Problems• Shock prob cardiogenic• Severe anemia prob sec to hemorrhage

Hgb Hct WBC Band Neut Lymph Mono Plt

57 20 42.7 6 45 41 8 188 70 nRBC

Cranial UltrasoundNormal

PT Control 13.3 Patient 38.5 % activity 0.2 INR 3.78aPTT Control 29.3 Patient 138

2D Echo

PA pressure 50Right to left shunting (PDA)Underfilled left ventricleSevere tricuspid regurgitationPFO bidirectional

PNSS 20mL/kg bolus 2xDopamine and Dobutamine DripBlood transfusion ordered but refused

Page 21: NICU Mortality

Problems

• InfectionHgb Hct WBC Band Neut Lymph Mono Plt

57 20 42.7 6 45 41 8 188 70 nRBC

Blood culure and sensitivity

No growth

CRP (NV 0-0.5mg/dL)

0.01mg/dL

Ampicillin 50mg/kg/doseGentamicin 4mg/kg/day

Page 22: NICU Mortality
Page 23: NICU Mortality

INTRACTABLE METABOLIC ACIDOSIS SECONDARY TO MULTIORGAN DYSFUNCTION SECONDARY TO PERINATAL ASPHYXIA

Final Diagnosis

Page 24: NICU Mortality

Learning Points

• Adequate communication between teams• Regular and proper evaluation of adequacy of

resuscitation

Page 25: NICU Mortality

THANK YOU!!!

Page 26: NICU Mortality

DISCUSSION

Page 27: NICU Mortality

Perinatal Asphyxia

• Condition of impaired gas exchange that leads to fetal hypoxemia and hypercarbia

• Occurs during the 1st and 2nd stage of labor• In term infants, 90% occur in antepartum or

intrapartum period as a result of impaired gas exchange across the pacenta

• Postpartum – secondary to pulmonary, cardiovascular, neurologic abnormalities

Cloherty J. Manual of Neonatal care, 6th ed

Page 28: NICU Mortality

Hypoxic-Ischemic Encephalopathy

• Abnormal neurobehavioral state in which the predominant pathogenic mechanism is impaired cerebral blood flow

• Suspected if:– AS <=3 at >5minutes– FHR <60 bpm– Prolonged (>1hr) acidosis– Seizures within the first 24-48hrs after birth– Burst-suppression patten EEG

• 20-30% of infants die in the neonatal periodCloherty J. Manual of Neonatal care, Lippincott Williams and Wilkins, 6th ed. 2008 p89

Kliegman R. et al. Nelson Textbook of Pediatrics, 19th Ed. 2011 p571

Page 29: NICU Mortality

Kliegman R. et al. Nelson Textbook of Pediatrics, 19th Ed. 2011 p571

Sarnat and Sarnat Staging for HIE

Page 30: NICU Mortality

Diagnostic Imaging

• Diffusion-weighted MRI

Kliegman R. et al. Nelson Textbook of Pediatrics, 19th Ed. 2011 p571

Page 31: NICU Mortality

Treatment

• Therapeutic hypothermia– decreases the rate of apoptosis and suppresses

production of mediators known to be neurotoxic, including extracellular glutamate, free radicals, nitric oxide, and lactate.

Kliegman R. et al. Nelson Textbook of Pediatrics, 19th Ed. 2011 p571

Page 32: NICU Mortality

Therapeutic Hypothermia

• >= 36 weeks AOG– Physiological criteria• Evidence of intrapartum hypoxia, including at least two

of the following: – 1.Apgar score 5 or less at 10 min – 2. Needing mechanical ventilation and/or

ongoingresuscitation at 10 min – 3. Metabolic or mixed acidosis defined as arterial cord gas, or

any blood gas within the first hour of life showing pH of 7 or less, or base deficit of ≥12 mmol/l

Mosalli R. Whole body cooling for infants with hypoxic-ischemic encephalopathy. J Clin Neonatol 2012;1:101-6.

Page 33: NICU Mortality

• Neurological criteria– One of the following: • Seizures is an automatic inclusion• Evidence of encephalopathy suggested a-EEG• Physical examination consistent with moderate to

severe encephalopathy

Therapeutic Hypothermia

Mosalli R. Whole body cooling for infants with hypoxic-ischemic encephalopathy. J Clin Neonatol 2012;1:101-6.

Page 34: NICU Mortality

Mosalli R. Whole body cooling for infants with hypoxic-ischemic encephalopathy. J Clin Neonatol 2012;1:101-6.

Page 35: NICU Mortality

Infants not Eligible for Cooling

• Birth weight less than 2000 g • Gestational age less than 36 weeks• Inability to initiate cooling by 6 h of age• Clinical coagulopathy• Life-threatening abnormalities of the cardiovascular or

respiratory systems such as complex congenital heart disease and PPHN

• Major congenital malformations, imperforate anus, suspected neuromuscular disorders, or presence of known lethal chromosomal anomaly

• Death appears inevitable

Mosalli R. Whole body cooling for infants with hypoxic-ischemic encephalopathy. J Clin Neonatol 2012;1:101-6.

Page 36: NICU Mortality

PROTOCOL

Page 37: NICU Mortality

PROTOCOL

Page 38: NICU Mortality

Specific Supportive Treatment during Hypothermia

• Respiratory support – assisted ventilation, keep 02 at 92-98%

• Cardiovascular support– asymptomatic sinus bradycardia without cardiac

dysfunction– At 33.5°C, the average HR is 80–100 beats per minute

bpm– If inotropic support is required, the following regime is

suggested:• Dopamine up to 10 mg/kg/min • If still hypotensive add dobutamine up to10 mg/kg/min

Page 39: NICU Mortality

• Fluids– Start with 50–60 ml/kg/day– insert urinary catheter to measure urine output

• Electrolytes– Na and Cl levels could fall duet o increased renal

loss in hypothermia• Coagulation– mild derangement of blood viscosity and

coagulation

Specific Supportive Treatment during Hypothermia

Page 40: NICU Mortality

Rewarming Procedure

• increase the rectal temperature to 36.5–37°C at a rate not to exceed 0.5°C per hour.

• final temperature goal is 36.5°C and should take about 7 hrs to achieve.

Page 41: NICU Mortality

Prognosis

• Infants with initial cord or initial blood pH <6.7 – 90% risk for death or severe neurodevelopmental

impairment at 18 mo of age. • Apgar scores of 0-3 at 5 min, high base deficit

(>20-25 mmol/L), decerebrate posture, and lack of spontaneous activity are also at increased risk for death or impairment.

Page 42: NICU Mortality

Thank you!