الرحيم الرحمن الله بسم

Neonatology At a glance

Author

Dr / Ali Abdel-Hakam

Computerized By

Dr / Noha Mokhtar Dr / Ola Allam

Dr / Mai Ghanem Dr / Randa Mohamed

Dr / Mervat Fathy Dr / Ahmed Khatab

Dr / Ahmed El-kalashy Dr / Ahmed Omar

Dr / wagdy Assar Dr / Ahmed Ez-Eldeen

Dr / Amr Gamal Soliman Dr /Ahmed Sorour1

Special Thanks to Dr / Ahmed Abdel-Hakam

1st Edition , September 2012

والمؤمنون ورسوله عملكم الله فسيرى اعملوا وقل ) إلى وستردون هادة الغيب عالم كنتم بما فينبئكم والش

(   تعملون

Patients trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:

Make the care of your patient your first concern Protect and promote the health of patients and the public

Provide a good standard of practice and care

o Keep your professional knowledge and skills up to date

o Recognize and work within the limits of your competence

o Work with colleagues in the ways that best serve patients' interests

Treat patients as individuals and respect their dignity

o Treat patients politely and considerately

o Respect patients' right to confidentiality

Work in partnership with patients

o Listen to patients and respond to their concerns and preferences

o Give patients the information they want or need in a way they can understand

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o Respect patients' right to reach decisions with you about their treatment and care

o Support patients in caring for themselves to improve and maintain their health

Be honest and open and act with integrity

o Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk

o Never discriminate unfairly against patients or colleagues

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

Author

علي. الحكم عبد د

Special Thanks to Dr / Ali Abdel-Hakam

Dr / Noha Mokhtar

Dr / wagdy Assar

Dr / Ahmed Sorour

Lecture Page

History 1Examination 3The Report 5I.V. Fluids 6G I ratio 10

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Blood & Plasma 11Dehydration 13Feeding 14Drugs 21Sets الجلسات 29Post vent. Care 30A,B,G notes 31Full & Preterm Sings 34During your shift 36Nursing care 37Respiratory distress 38HMD 39Broncho-pulmonary dysplasia 41Meconium aspiration syndrome 42TTN 44Pneumonia 45Pulm. Hemorrhage 46Pulm. Hypertension 47Pneumothorax 48Neonatal cyanosis 51Apnea 53

Lecture Page

CPR 54Vomiting 55Diaphragmatic hernia 56Infant of diabetic Mother 56Prematurity 59I.U.G.R. 61Jaundice 61Neonatal convulsions 69CNS Infections 71UVC 72

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ETT 73Hyperglycemia 75Hypoglycemia 76Hypocalcemia 78Hypotension & Shock 78Hypertension 79Hyperthermia 80Hypothermia 80

المتابعه حاالت 81Poor perfusion 82Tachycardia 82Bradycardia 82NEC 83D.D. of tense Fontanels 83I.C.H 84Edema 84Down Syndrome 85

History5

(Done in 1st report)

1) Name : Mother’s name + child’s name + المولود اسم األم اسم2) Sex ( male or female ) : medico legal 3) Residence 4) Sibling : إخــواته وســط الترتيب

- See if precious baby. - If ↑ number of siblings take care of D.M. + Large baby

5) Consanguinity for congenital anomalies 6) C.S. or Vaginal delivery

+ Maternal administration of cortisone if early labor

Vaginal delivery C.S.1- Labor pain طلق جالها

( spontaneous , induced )

2- Obstructed \ difficult labor متعسرة كانت هل و إيه قد الوالدة مدة

1- Why?? ليــــه e.g. - Pre-eclampsia حمل تسمم- Heart disease- D.M.- Obstruction - PROM + المدة

7) Age of baby : يوم كام المولود عمر esp. in Jaundice ,and if it started at 1st day or not

8) Full term or Preterm في معانا تفرق و الكام الشهر في اتولد ، ميعاده قبل ال و ميعاده في اتولد

- Food - Ventilation - Other problems of Preterm

9) Maternal history of : - D.M. جداهــــام → I.D.M.- HTN ( Pre-eclampsia )

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Why we ask about these items? إيه في معايا هيفرق ودهObstructed labor ( vaginal ) leads to :- Caput succedaneum - Cephalohematoma ( esp. with forceps)- Cephalohematoma :leads to anemia , Jaundice - Traumatic cyanosis ( خالل تختفي و أزرق الجبهه يوم 2-1لون )C.S. liable for respiratory distress as vaginal delivery compress secretions out , So may find TTN.Anesthesia in C.S. affect in respiration.D.M. → infant of diabetic mother.Heart disease → congenital heart disease في أشك

- PROM بدري نزلت الميه(If MAS) أل ال و منها شرب الطفل هل وSepsis من أكتر لو الخطوره عشان 24و ساعه Triple antibiotics بـــــ العالج نبدأ ساعتها وN.B. PROM > 3 months → lead to creation of stressful environment around the baby >>>> corticosteroid release & lung maturity

10) Conditions of baby just after birth : اتولد لما الواد- Cry أل ال و عيط- Cyanosis أل ال و سريع تنفسه و أزرق- Any problems تانية مشاكل أي في- Need incubator or not حضانه قالولك ليهمحتاج - MAS

11) Presentations by : - Respiratory distress , grads :

I. >>TachypneaII. >> I + RetractionIII. >> II + Grunting IV. >> III + Central Cyanosis

- Jaundice - Meconium aspiration - Pneumonia - convulsions

12) Report في : الدبـــــــــاجة- السابق الوزن

الحالي الوزن- بالوحدة \ األيام عدد باليوم الطفل عمر- الساعة , اليوم- مناسبة : الحضانة حرارة

----- : الساعة- : األكسجين

1- Nasal : maximum 2 L \ min2- CPAP : ---- %3- IMV ( Intermittent Mechanical Ventilation )4- A\C ( Assisted ventilation ) 5- SIMV ( Synchronized IMV )

- الضوئي : العالج فردي زوجي ثالثي

N.B. In case of Jaundice, ask about:

- Time of start جدا أل الحظتوها , هام ال و يوم أول7

- Previous J. baby

- Feeding pattern جدا هام- Rh + ABO جدا هام- Prenatal, natal, Postnatal History

- Family history of hemolysis

Examination 1) General :

1. Look for appearance :

- Large baby →IDM

- Small baby →IUGR or Preterm

2. Colors هـــــام :

- Pallor ( in lip , nails esp. if cyanosed as the blue color mask pallor)

- Jaundice ( in the body better than eye )

- Cyanosis ( central or peripheral )

- Mottling بطش : poor perfusion in ( anemia , acidosis)

3. Activity جدا : هام

↓ Activity - poor suckling → Sepsis (1st alarm)Don’t judge on baby with IMV → because he is sedated

4. weight

2) Head :

1. Shape of head : microcephaly , macrocephaly ( hydrocephalous )

Centile chart الــــ على نحطه و الراس محيط نقيس2. Fontanels :

- opened or closed

- Normally: Ant. 2 cm & Post. Closed

- Bulging fontanel : CNS presser esp. if with convulsions

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(IC hg, encephalitis, hydrocephalous) - Depressed : indicate dehydration

3. Face : colors

4. Dysmorphic features : cleft lip or palate

5. Suckling : good or poor

3 -Chest

-Rate counted / 1 min , as neonate has cyclic respiration

(Don't count RR after suckling , due to there is some exertion with tachypnea which disappear after few minutes)

-Symmetry between 2 sides ( no bulging or depression )

-Signs & Grades of RD ( I , II , III , IV )

-Auscultation : air entry in 2 sides equal or not ( listen at MCL & MAL ) & presence

of additional sounds as Wheezes or Crepitation

-Don't forget grunting :- listen to his voice

4 -Abdomen

a. umbilicus: if there is signs of infection or not as it is important source of

infection.

b. distention

c. liver and spleen palpation

d .intestinal sounds : if heard ,suckling is allowed.

5 -Genitalia:

to exclude congenital anomalies, examine both testes and anus to exclude imperforate anus.

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6- Heart

-S1,S2

-murmurs (may not be present in the 1st three days even with congenital heart)

-bradycardia ,tachycardia

-blood pressure

-capillary refill time (for perfusion)

sepsis ال حاالت في تنقل.... أيدك وتشيل sternum ال على تضغط

7- Sepsis

Clinical picture:

1.hypothermia or fever

2.decreased activity :very important

3.hypoglycemia due to hypothermia and the reverse is true

4.decreased motility

5.system impairment (score >3) (every item take one )

A .Heart: tachycardia or bradycardia (<120)

B .Renal : oliguria

C .Respiratory : tachypnea , bradyapnea

D .CNS : convulsions ,lethargy, DIC and disturbed level of consciousness.

8-Cannula

Extravasation ,tissue necrosis with Ca.

Edema : you will find place of cannula either blue or red.

أطول. مدة هيفضل الولد لو UAC تركب ممكن و تتسد لما تتشال

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Investigations(routine): -9

-CBC - CRP - Chest X-ray - ABG

-TLC : leucocytosis or leucopenia (normal value 4000 :11000)

10 -limbs

A . tone :frog leg , flaccidity

B .edema in lower limbs :give lasix and plasma

11- Reflexes : the most important reflexes are Moro and suckling reflexes

12 -Skin:

A . pinch for dehydration if on phototherapy.

B . press : if perfusion > 3 sec delay , give dopamine.

C . sclerema >>>> sepsis

D . ecchymosis >>>> anemia ,PT

Normal examination

CNS: Good general conditions , Active cry , Good suckling , +ve Moro reflex

Respiratory: Equal air entry bilaterally , No adventious sounds

CVS : Normal S1,S2 , No murmurs

GIT : Lax abdomen , No organomegally , Intestinal sounds

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Reportالتقرير

Items

1 . history :

D / D- بالوحدة األيام عدد/ باليوم الطفل عمر

-Male or female - Cesarean section or vaginal delivery

-DM , HTN , PROM

2 . Age

3. Presentation ………-:

NB: - type of Oxygen :- now he is on …… (esp IMV)

4 . Examination

A . general examination:

1.body weight 2.pulse ,BP, temperature and fontanelles

3.RR ,colors ,suckling and feeding

B . local examination

1.Chest: .RR , chest symmetry , air entry , crepitations, wheezes and grunting .

2.Heart : S1 ,S2 , murmers and perfusion.

3.Abdomen:distention ,lax or not and if there is hepatomegaly

5 . Investigations done :

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6. Treatment : especially last treatment >>> Fluids , Drugs , Phototherapy , O2

7 . Recommendations

IV fluidsالمحاليل

فقط( للقراءه) نظري معلومات أوال

Indications:

1 -all sick babies 2- babies with low blood sugar

3 -all babies weighting <1,800 gm 4- RD ( R.R >80 or grade II , III , IV)

5 -ventillated or CPAP infant 6- dehydration

7 -all babies who is NPO or who can't take an adequate amount of fluids with nipple or tube feeding

Solutions:

1 -dextrose: 5% - 10% - 25% ( 5% means 100 c.c >>>>5 gm )

2 -normal saline : ( Ns ) .9% ….each 100 ml has 15.4 mEq Na & 15.4 cl& .9 Nacl

3 -Kcl (potassium chloride ): ( 15% 1mmol for each 100 ml fluids )

4 -Ca gluconate 10 % >>>ca

5 -neo/ment : in < 30 day

-glucose 12 % (12.5% ) - saline -potassium -No Ca

6-pediament:contains ca given if the infant > 30 day

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Monitoring I.V fluids:

1-day to day change in body weight

2-volume of urine out put : ( normally 1-2 ml / kg /hr )

3 -general app. & and vital signs

4-urine s. Gravity & blood electrolytes( Na , K , CA)

When to discontinue:

رضاعة- الوصول عند) (3/ سم 20 ل ساعات 1 -has adequate calories intake & fluid by nipple or tube feeding ( 120 ml

/kg/day)

2-has recovered from an illness

3 -no longer needs I.V for glucose

I.Vال نحتاج احيانا ولكن الكاملة للرضاعة الوصول مع I.V Line ال نشيل بكدهline عليه للمحافظة لذا ادوية إلعطاء :

1 -allow 1ml /hr continuous I.V infusion to keep the canal patent

2 -flush periodically with 1ml heparinized saline ( not done )

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التطبيق العملي إلعطاء المحاليل )هام جدا(

A- In babies less than 30 days:

1 -During the 1st day of life

-what to give:

-Glucose 10 %

-Glucose 7,5 % or 5% if preterm less than 1.5 kg(N.B: glucose 7.5 by mix

glucose 5% ,10 % by1:1)

-Ca : not in 1st day except in ( Ca is withdrawn if HR <120 )

1 -infant of diabetic mother 2-preterm

3-hypocalcemia 4-hypoxia 5-perinatal asphyxia 6- HIE

-NB: ca is withdrawn if HR<120

-Amount: ( according to weight )

< -2 kg >>> 90 ml /kg /day

-2 - 2.5 kg >>>> 80 ml /kg/day

-2.5 – 3 kg >>> 70 ml/kg/day

> -3 kg >>>> 60 ml/kg/day

2 -During 2nd day of life

-what to give:

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1-Neoment

2-Ca : 1cc.c / kg /day ( divided on 4 doses )

3-if no pass urine : give >> glucose 10% + 13 ml Ns / kg + 4 ml ca /kg

NB -stop Ca when feeding reach 15 cc milk / 3hs

-Amount

increase by 10-20 ml/kg till reach 150ml/kg/day

التخصيم -

المحاليل من االتى من كل يخصم

االدويه- 2. الرضاعه-1

علي يحتوي سوف Net fluids ال ويسمى الباقي**

Aminovein - )) ,, ))ال من جزء هو ولكن النيومنت كميه على للحصول يخصم NF

Neoment -

Dormicum , dopamine or any drugs which is add to solutions -

rate ال على للحصول 24 على الباقي يقسم-

:- التذكرة فى فعليا يكتب ما-

-TF ( total fluid ) = ……… ( this is the amount that enter circulation )

-Dr ( drugs ) = …….. Calculate the total amount of drugs for this day

-Feeding = ……….. the total amount of feeding for this day

-NF ( net fluid ) =……….. include neoment + aminovein + drugs on them

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:- الدم او البالزما تخصيم**

line iv ال نفس في تعطى النها تخصم ال ممكن-

كالتى تخصم او-

Ex: we give iv fluids by rate 6cc/hr & give plasma by 10cc/hr for 24hr so in 2hr we give 20cc plasma& 12cc iv fluids so ,

20 – 12 = 8 cc = التخصيم

3-During the third day of life

Add aminovein if : baby micturate &still no feeding till 3rd day ((esp. if edema is present ,or preterm baby(start here by 1.5) ))

stop it in:

1-feeding 15 cm/3hr 2- renal problems( due to increased protein)& use plasma here

Dose:

Start with 0.5 gm/kg/day or 1gm (the best ) or 1.5 gm ( different schools )

او, يوم 0.5gm/kg زياده مع على) كل ويوم .Max ل منوصل لحد( الحاجة حسب يومdose وهى

FT >> 3gm/kg/day

PT >>3.5/kg/day

X 10 الجرعة X الوزن= ومعادلته

NB:- Concentration of aminovein 10 cm / 1 gm

واالمينوفين الكالسيوم بإيقاف قم..... ساعات 3/ رضاعه سم15 ل الوصول عند-

لو اال جدا قليله هتكون النها المحاليل بإيقاف قم..... ساعات3سم/20 ل الوصول وعند- سبق كما line محتاج

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B ) In babies more than 30days :

We give pediament without giving Ca as it contain Ca

Max of pediament 100cc/kg/day

يرضع قادر ومش RD مثال فيه كان لو ويعطى كالسيوم فيه وده

كاالتى خلطه نعمل موجود مش ولو

Glucose : saline = 4 : 1 + ( kcl 1cc for each 100ml fluid )

*N.B: max of neoment >> 150

Special cases

- Preterm < 1.5 give Glucose 7.5 or 5% in the 1st day to avoid hyperglycemia but better guided by RBS- Jaundice لو اال عادى بيرضع ده

1st day or on 3 photo .>>dehydration &give 20cm/photoالحقا .... - الخلطات

لو:- بكام؟ نبدأ محاليل وهياخدRD وعنده عمره من الرابع فاليوم داخل الطفل استفسار

البدايه دي وهتبقى عمره من يوم كل على 10 وزود يوم اول كأنه وزنه على احسب

150 ب طول على معاه هنبدأ كيلو 2.5 ووزنه 12 اليوم جاي واد لو-

NB:- Dose of pediament

1st 10 kg>> 100ml/kg

2nd 10 kg>>50ml/kg

Above 20 >>20ml/kg

.100 الجرعه لذا كيلو 10 يعدي الطفل ان صعب وطبعا دائما ... امينوفين ياخد المفروض ولسه صفر يساوى NF ال طلعت الحسابات لو:- ملحوظة

الساعة... فى سم 1 بمعدل ومشيها لألمينوفين مساوية Emprical نيومينت كمية ضعكويس بيرضع هيكون الطفل غالبا وساعتها

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Restriction

*20% ( TF X 0.8 ) in case of :

-Chest(RDS - meconium aspiration - pneumothorax)

*30% ( TF X 0.7 ) in case of: IC Hge - Cardiac (overload) – hydrocephalus – CNS

(brain edema> tense fontanel -)renal

*No restriction& even addition in case of:

*sepsis: *Dehydration:

1-poor feeding2-hypo or hyperthermia3-hpo or hyperglycemia4-hypoactivity5-hepatomegally6-sclerma7-jaundice8-DIC

1-dry tongue2-suken eye3-depressed fontanel4-pinch test which is inaccurate in

PT as there is little or no SC fat

Addition

1-10%for each photo ( so double >> 20 % )

ده من ده اطرح restriction هناك ولو

2-extreme low birth weight >> sepsis – dehydration

NB:- To calculate 120 % >>> multiply TF * 1.2

Why restriction?

In previously mentioned cases there is SIADH (syndrome of inappropriate ADH secretion) >> increase ADH >> fluid retention by 10-20%

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Shock therapy?

In case of shock: pallor - cold clammy skin - rapid thready pulse

Dose :10-20ml /kg over 30 1hr normal saline or ringer lactate

Glucose Infusion Ratio ) GIR ( هـــام في للطفل داخله اللي الجلوكوز كمية ساعة 24هي : المعـــادله

- Normally : GIR = 4 – 8 mg \ kg \ minMaximum is 12 , Minimum is 4

- Uses in cases of hypoglycemia & hyperglycemia - In hypoglycemia :

يتعدى ال أنــه الـ 12بشرط وصــل لو ،12 GIR الــ هنـــزودCorticosteroids هنــدي hypoglycemia الطفـــل مازال و

- In hyperglycemia :4لحـــــد GIR هنقــــلل

Insulin هنــدي hyperglycemia الطفـــل مازال و

- N.B. Sepsis الـــ نستبعد االول الــ hyperglycemia الزم حاالت في Canula ال الزم علي نشيت hypoglycemia الـــ حاالت في

Sepsis نستبعد وطبعا قليلة تكون ممكن ألنها المحاليل تراجع و عطلت تكون ممكن ألنها ال

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لجميع الدعاء نسألكمالعمل هذا في Jالمشاركين

or

- Now the question is how to control GIR ?By changing glucose concentration (eg. Replacing G 10% by G 7.5%)Rate الـــ بتغيــير ليس و المحاليل في التركيز بتغيـــــير أيTo avoid volume overload

Blood & Plasma① Plasma :

- Indications : (االهم)1- Sever sepsis ( as it contains Ig ) ,2- bleeding tendency3- Edema ( osmotic effect ) every 12 hr if sever

- Dose : 15 ml \ kg \ dose - مدار على الساعات ( \ )3 – 2تعطى عدد الجرعة بمعدل ساعات- e.g. >>> Request الريكويست كتابه عند

على 15 والتوافق الفصيلة عمل بعد الفصيلة نفس من طازجة بشرية بالزما سمبمعدل 3-2مدار ســـاعات

ـــــــــــ②Blood ( packed RBCs ) :

- Indications : anemia (judge by degree of pallor plus HB level esp. if < 10 gm/dl) but take care of laboratory mistakes so c/p is important.

- sever ecchymosis - Dose : 10 ml \ kg \ dose & 15 ml \ kg \ dose in sever anemia - e.g. for the request

مدار 15 على التوافق و الفصيلة عمل بعد الفصيلة نفس من حمراء دم كرات سمبمعدل ـــــــــ ــــــساعة

N.B.

- Whole blood ( موجود ml \ kg \ dose 20 → ( مش

بينهم - يكون الزم بالزما و دم هتاخد حاله ساعات 6 – 4لوال التتجاوز صالحيته عشان االول الدم ساعات 6وندي

- After blood or plasma , we need to :

1-Measure blood pressure

2-Give lasix to decrease overload الطفل وزن نفس )9 + 1 ( ويحل الزكس

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هدف لك يكون أن البدبحياتك لتستمتع

N.B.

- Challenge test ( preterm no urine + edema )

If patient with no urine :give fluids ( shock therapy or plasma ) then lasix within 20 min then see urine out put :

If +ve → pre renal failure ( hypovolemia and so measure the BP )

If –ve → renal or post renal causes

N.B.- Plasma given if aminonein Is contraindicated esp. if ↑ urea & creat

Also if plasma is given stop aminovein for that day.

Transfusion of RBCs & Plasmaنظري معلومات

① Packed Red Blood Cells :

- Indications :1- Ideal for who requiring red cells not volume .2- ↑O2 carrying capacity of blood in a cutely in infants with sever RDs & on

IMV .3- Try to maintain HB > 13 gm \ dl .4- Cardiac patients ( cyanosis , HF ) .5- Symptomatic anemia ( tachypnea , apnea , tachycardia , bradycardia , ↓

feeding , lethargy , pallor ) .

② Fresh Frozen Plasma :

- Indications :1- Replace clotting factors – TTT of shock .2- Dilutional exchange transfusion .3- Sepsis – DIC .4- Premature .5- Sever RD , coagulation disorders .

No cross matching or ABO compatibility is needed for the plasma.

Both warmed to 37oc before transfusion , But by blood warmers not direct heat to avoid → Agglutination .

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Dehydrationكتير بنشوفه مش الن ده الموضوع عن قليله معلومات دي

Types of dehydration Therapy :

① Step I : shock therapy

10 – 20 ml \ kg \ dose مـــدار إلى 20على دقيقه 30دقيقه

② Step II : Deficit therapy

- If can drink → √√ or محالـــــيل

- Mild degree 40 ml \ kg \ 8 hr ,Moderate degree 80 ml \ kg\8 hr , Sever degree

120 ml \ kg \ 8 hr

③ Step III : Maintenance therapy

1st 10 kg → 100 cm \ kg \ day , 2nd 10 kg → 50 cm \ kg \ day ,

3rd 10 kg → 20 cm \ kg \ day

How to diagnose :

1- Dry Tongue األهــم 2- Depressed Fontanels 3- Fever 4- Hyperglycemia 5- Decrease urine out put

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صدقة االبتسامةJ

Feeding التغـــــذيــة

فقط للقــراءة نظـري معلومــــات

Types of feeding :1) Enteral nutrition :

- Breast feeding- Bottle feeding - Tube feeding ( Gavage feeding )

2) Parental feeding بالمحالـــيل

Enteral nutrition :- Types of milk :

1) Breast milk2) Expressed breast milk3) Standard formula 4) Premature formula 5) Special formula : - low phenylalanine , - low phosphate , - S26AR كتير بترجع اللى االطفال فى استخدامه يفضل

N.B. Calories :

-To maintain weight & essential body functions , The baby needs 50 – 60 Kcal \ kg \ day.

-To induce weight gain .

Full term give 100 – 120 Kcal \ kg \ day , Preterm give 110 – 140 Kcal \ kg \ day .

-Formulas :

ordinary → 100 cc → 67 Kcal , Premature → 100 cc → 81 Kcal .

-To calculate total daily calories :

24Kcal \ kg \ day =

When to start enteral feeding : هــــام

1- if baby has good suckling with no history of excessive oral secretions .

2- not distended soft abdomen with normal sounds .

3- RR < 60 br \ min for oral feeding & < 90 br \ min for Gavage (Ryle) feeding.

4- For premature infants :

- Feeding should be initiated as soon as clinically possible .- Early entered feeding is associated with better endocrinal adaptation ,

enhanced immune functions & earlies discharge .- Feeding is started in 1st 3 days of life , aiming for full entered feeding in 2-3 weeks .- For stable , larger premature infants > 1500 gm , the 1st feeding هــام

may be given within the 1st 24 hrs of the life , early feeding may allow the release of enteric hormones which exert trophic effect on intestine .

5- For sick infants of any birth weight , usually have concomitant ileus , So start only if :

- The baby’s condition is improving . - They don’t have abdominal distention .- They passed meconium .- They have normal bowel sounds .

6- Prescience of umbilical catheter is not an absolute contraindication for feeding .

When not to give Enteral feeding :1- When gastric aspirate every 4 hrs is more than the milk given .2- If there are signs of intestinal obstruction .3- If feeding triggers apneic attacks .4- In the acute phase of any illness , the 1st 24-48 hours , or while bowel

sounds are absent .5- In babies with NEC .6- In 12 hr post extubation .7- In babies with repeated convulsions ( aspiration ) .8- During exchange transfusion .

25

Babies at risk of developing feeding difficulties :

Warning sign Action

Excessive mucus , frothy secretion or history of maternal poly hydramonus

Don’t feed till you pass a tube into the baby stomach to exclude esophageal atresia .

Distended abdomen

Insert NG or OG tube & withdrawal air / fluid to decompress the babies stomach , don’t feed till rule out obstruction Or illus .

RD , rapid breathing or depressed activity هـــام

Don’t feed by bottle nor allow breast feeding until RR is about ??? & the baby can co-ordinate suckling , swallowing , breathing .

Premature infants < 32-34 wk may able to suck , swallow & breath , but usually can’t co-ordinate these activities

Feed by NG or OG or IVF till tube feeding can be administrated .

Vomiting of green material or persistent vomiting or spitting

Stop feeding & obtain Abdominal X-ray to evaluate for possible I.O.

No meconium by 48 hr of age Stop feeding until you evaluate for obstruction .

Babies who required prolonged resuscitation

Keep NPO till baby is stable for 24-48 hr till bowel sounds appear to avoid NEC & renal pr. .

Excessive gagging , irritation & secretion due to NG tube

Remove NG tube , give bolus feeds by OG tube .

Regurgitation , vomiting & Abdominal Distention

Suspect sepsis . NEC or intestinal obstruction .

Excessive gastric residual Decrease the volume of next feed & ↑ more gradual , use jejunal route

Tube feeding : NG or OG

When are tube feeding required :

1- Preterm babes < 32 – 34 W. gestation.

26

Some babes are able to do sucking , swallowing, breathing & gagging but coordination between these activities may be deficient2- Infants weighting < 1.4 KG ( poor suckling )3- For certain sick babes : > 34 W with certain conditions that prevent them from

being fed safety with nipple : * Severe neurological problems : with absent gag reflex * Babies who tires easily from exertion from nipple feeding4- Babes recovering from RD but still tachypneic ( RR > 60 Br. / Min. )

When to stop tube feeding :

1 – when they are no longer needed :

- The infant developed gag reflex & can coordinate suckling , swallowing & breathing

- No respiratory problems2- when they are not tolerated : significant residual volume is found consistently before each feeding or if bile appears in residual stop tube feeding start IVF and investigate the case3 – if respiratory distress is increased : RR > 90 Br. / Min.

Complications

1- Malposition : tube to airway2- Over & under feeding3- Perforation of esophagus , stomach or ulcer at mucosa

27

) ( وعن وسلم عليه الله صلى محمد نبيك عن دافعصوتك بعلو ال بأخالقك إسالمك

Clinical application )هام جدا(

ده التطبيق العملي في موضوع التغذيه

When to start

Method Dose (FT , PT ) األدوية المشاكل

1- When to start ?

-Usually , not in the first day

-usually Not in infant on IMV or CPAP(some prefer to start feeding on IMV & CPAP)

-When respiratory distress resolves

(( RD >> no feeding for fear of aspiration ( As swallowing reflex and respiration are

still not coordinated ) . ))

-Do 1st gastric wash > if clear > start

2- Method ?

- 1st by Ryle then by suckling (when to shift >> see N.B. )

3- Dose ?

A) Full term baby :

-Start trophic feeding : ساعات 3/ سم5 ب ابدأ ( fixed ) 28

Clear نظيف ويكون معدة غسيل عمل بعد طبعا وده

وزود 11 11 99 77 55 كاآلتي التكرار ويكون رضعة ثالث كل سم 2 زود يوم ثاني -لـ توصل ما لحد مشاكل مفيش طالما يوم كل Full dose 30 cm / 3 h r اكتب وبعدها

الحاجة حسب رضاعة

ابطأ( ولكن االحسن) أخرى طريقة

ساعات 3/ سم 5 األول اليوم15 – 10 المعادلة استخدم الثاني اليوم ml / kg / day( محتاجها الي الزياده دي )

ساعات 3 كل وادي 8 على اقسمه والناتج االول اليوم رضعات علي اجمعه رقم هيطلعالرضاعة كدا fixed ))

قبله اللي اليوم رضاعة عليه واجمع الجديد وزنه على المعادلة احسب: التاني اليوم فيوهكذا 8 على اقسم ثم .....

الواحد اليوم في الرضاعة أن هنا الميزة fixed

ال على أسهل وده Tolerate easily <<<< GIT

نقص أو زيادة بدون محتاجها اللي الكمية بياخد

ترضع األم نجيب امتى

1.5- 1 ل يوصل KG

2- Full dose + bottle(good suckling)

B) preterm

ال من بنخاف أننا المشكلة - NEC بالراحة نبدأ لذابعد( كمان سم 1 أو) ساعات6/ سم 2 ب ابدأ - clear gastric wash

رضعة ثالث كل سم 2 زود ثم كويسة الدنيا لو ساعات 3/ سم 2 ادي يوم ثاني -

أخرى طريقة

ساعات 6/ سم 2 ب ابدأ -29

يوم تاني من المعادلة استخدم ثم يوم أول -

-: ملحوظة

ال وشيل األمينوفيلين شيل< ساعات 3/ سم 15 ل الوصول عند - Ca

لو إال قوي قليلة هتكون ألنها المحاليل شيل< ساعات 3/ سم 20 ل الوصول عند -ال عايز أنت canula ب مشيها rate بطيء

ترضعه تيجي أمه+ الحاجة حسب رضاعة< ساعات 3/ سم 30 ل الوصول عند -

4) Drugs :- (Prophylactic )

Prokinetic (regulates motility) >Motiluim , H2 blocker > Zantac

Decrease distention > Simithicone

*Some say if the case take dopamine or doputamine they should be stopped but

وقف ثم للنص أنزل والدوبامين يوقف الدوبتركس ) ) gradually

As they cause V.C. at splanchnic vessels & so > tolerance

* االدويه ياخد الي مين طب

نريح عشان والسايمسكون الموتيليم خاصه بيرضع الي كل مع توخذ انها االحسن gitال

زي مشاكل يحصل لما نديهم بيقول راي فيه distension

5) monitoring & complications

بعد التنقس معدل زيادة – انتفاخ – ترجيع حدوث مالحظة مع) التذكرة في يكتب الرضعة(

) السابقه الرضعه من تبقي ما ) -- Monitoring : by Ryle > see the residual

1) 1st problem >> residual

30

No residual أصفر أو أبيض brownish

Continue as the regimen

< 10% (or 20%)

تاني اديلهرضاعة كمل +

الجرعة بنفس ( تزود ما بدون)

> 10% (or 20%)

رضعة فوت من ده واخصم

الرضعات كمية كده بعد اللي

Means gastritis

وادي الرضاعة وقف ومحاليل زانتاك

وكوناكيون

2 ) 2nd problem : distention

رضعتين : لمدة الرضعة وبعد قبل بالمازورة البطن محيط قياس ب يشخص أوالانتفاخ <<< ده يبقى بعدها اللي الرضعة قبل وزاد مثال رقم كان لو

Give glycerin sup. + Motiluim+ Simithicone

Do CRP > why ?ال من الخوف عالي Sepsis وال NEC كل فلو

Stop feeding & shift to IV fluids

ال لو ما suckling أما لحد رضعة فوت أو شوية الرضعة قلل كويس عامة والواديقل االنتفاخ

3 ) 3rd problem : tachypnea

عن ابحث < >الرضعه بعدكتير استمرت لو إال الواد على مجهود ده ألن عادي وده ( للرايل ارجع)الببرونة رضاعة ووقف السبب

N.Bs

1 بالببرونة؟؟ رضاعة ابدأ امتى )

-NG residual with Ryle

ساعات 3/ سم10 وصلت -

-RR < 60 Br/min - Suckling is good

31

NB:- when to continue with Ryle even if the previous three conditions exist ?

1- anemia ( as suckling is much effort for baby)

2- if the suckling leads to increased RD a lot.

2) 1st day of any diseased neonate > NPO + Ryle (opened to get rid of secretion) > if on nasal / CPAP

3) In RDS :

RR >90 NPO , RR 60 – 90 Ryle , RR < 60 oral feeding

4) stop aminovelin when reach 15cm / 3hr

ال لو residual 5 تعمل وبالش رضاعة توقف وال ترميه اوعى مهضوم ) Ryle Aspiration

يعمل ده علشان زيادة لرضعة asphyxia + vagal stimulation

6) zantac not given in sepsis ( as it decrease gastric acid which is an important line for defense

ساعات 3 / سم 30 ل الوصول عند

)Full amount (؟؟ إزاي هانزود

ياخد ما زي< الحاجة حسب رضاعة بنكتب أوال -

يـــ الواد عايزين احنا لو لكن - << > gain weight

* Calculate needed calories–usually the range between 120 – 150 K. Cal/ kg/ day

* Take e.g. we now want to make 2 KG baby gain weight using 150 Kcal/ kg/ day:

كام هيحتاج هو هنحسب أوال -1 K.cal / day = 150 X 2 = 300 K cal

كام فيه هياخده اللي اللبن شوف -2 K.cal \ 100 cm 100 مثل cc > 67 K.cal

ده اللبن من سم كام هيحتاج الواد نحسب -3100 >> 67

32

??? << 300

الرضعات عدد عشان 8 على يقسم والناتج -4

كام بياخد الواد لمعرفة:- ملحوظة K.cal / Kg اآلن30 cc / 3 hr so 30 X 8 = 240 cc/day

100 >>> 67

240 >>> ???

كيلو لكل كالوري كيلو كام< الوزن على يقسم والناتج

ال تزوده وعايز دي الزيادة هيستحمل مش الواد لو طب:- ملحوظة K.cal نعمل ؟؟ إيه

40= زيت سم 1 ألن ذرة زيت( سم 1 ._5) زيت معلقة نضيف K.cal

كل أو) رضعة ثالث كل ذرة زيت سم 5. زيادة مع ساعات 3/ سم 30 ونكتب( ورضعة رضعة

– 3 فيت بيبي– 2 دروب في– 1.......... الوزن لزياده أدوية:- ملحوظةأسيد فوليك

4 _ فيت بولي_ 6 فور الكتويل_5 كارنتين ال

Drugs

Antibiotics :-

A) uses :

1- any invasive procedure eg canula

2- when to start immediately :- e.g. - history of PROM > 24 hr & we give triple

antibiotics.

33

B) when to change AB :- If 3 days with no response (clinically & CRP )

C) Duration :-

( الكانيوال نوقف ما لحد= كويس الواد طالما ) + CRP – ve

1- if no evidence of infection. (CRP – ve) >>>>> 7 days

2- if there evidence of infection. (CRP + ve) >>>>> 14 days

3- if CNS evidence of infection.>>>>> = 21 days

d) Flow up by CBC & CRP after 7 days

Lines of drugs:-

1st line drugs :- Unasyn – Amikin – Ampicillin – Garamycin

2nd line drugs :-

ميماكس – فانكو – كالفوران - كستاوفسي- سيفازيم – فورتم

3rd line drugs :-

مائى بنسيللين- سيبرو – تينام – ميرونام

NB :- sually start with unasyn – amikin ( you can add fortum as atriple therapy in some cases )

-if no response >> give Vanco & Fortum

- If no response >> give Vanco & Meronam

- You can add Flagyl (anti-anaerobe ) & Diflucan (anti-fungal )34

- The last line of drugs is ceftriaxone & liquid penicillin

- Cipro isn't common used nowdays

NB :- Another regimen

1st line :- Ampicillin & garamycin

2nd line :- unasyn & fortum ( we can't add amikin as it nephrotoxic )

3rd line :- Vanco & fortum

4th line :- Vanco & Meronam

5th line :- liquid penicillin & ceftriaxone

الجرعة حساب معادلة التركيز / ( الوزن X الجرعة X التخفيف ) =

في الكمية على للحصول الجرعات عدد على تقسم الكامل لليوم المحسوبة الجرعةبالشرط أو بالسم الواحدة الجرعة

الطريقة

التوقيت الجرعة التخفيف االسم م

وريدي

كل األول األسبوع في الثاني وفي ساعة 12

ساعات 8 كل

يقسمعلى الناتج

علي 3 أو 2 عدد حسب

الجرعات

8.3/ مجم 375سم16.6/ مجم 750 سم/ مجم 1500

سم 33.3 األرقام تقرب ال

–20 – 10 إلى40

يوناسين150 m g / kg / day

يونيكتامالتراسيمسالبيست

1

فقط يوم 14 – 10 لمدة ويؤخذ

35

وريدي

1.2 من اقل الوزن لو

كل واحدة جرعة يعطى ساعة 24

يعطى 1.2 من اكبر لوساعة 12 كل

شرطة 7.5 12/ كيلو/

ساعة

2/ مجم 100سم

اميكين7.5 mg / kg / dose

(gram –ve )

2

-This drug is nephrotoxic so not given more than 7 days & not given more than 7 days & not given in renal or pre-renal failure e.g. generalized anasarca

If used > 7 days > asses renal functions (UREA & CREAT.)-

وريدي

ساعة 12 وزن نفسكل الطفل

ساعة 12

10/ مجم 500سم

فورتم100 mg / kg / day

سيفازيم: زيه – سيفوتكس –

كالفوران

3

Given in 3rd day if preterm or 5th in fullterm

ضمن األول اليوم من ويعطى (triple AB)

حاالت فيSepsis – umbilical catheter – cong. Infection – history of maternal UTI or

PROM

وريدي

ساعات 8 / X 3 الوزن 8 كلولو ساعات

بالمعادلة مشهتقسم

100/ مجم 500سم

فانكو15 mg \ kg \ dose

هتقسم مش

4

-Duration:12 – 14 for nephrotoxicity fear ( max 21 day )

وريدي

ساعات 8 X 4 الوزن 8 كل

ساعات

100/ مجم 500سم

تينام – ميرونام20 mg / kg / dose

5

36

حاالت في CNS infection يعدي ألنه التينام وليس الميرونام يعطى BBB

بجرعة ولكن

40 mg / kg / dose

الوزن أو X 8 / ساعات 8 كلFor gram –ve ( B-lactam)

وريدي

ساعة 12 100/ مجم 200سم

مش) سيبرو( مستخدم

10 mg / kg / dose

6

الطريقة التوقيت الجرعة التخفيف االسم مبالرايل ساعات 8 كل 5/ قرص نصف

5 جلوكوز سم %Antiviral لوفير

10 mg / kg / dose

مجم 400= القرص

7

وريدي ساعة 12 سم 2/ مجم 20

سم 2/ مجم 80

جنتاميسين5 – 7.5 mg / kg / day

8

In case of infective endocarditis ( fever + cong heart )

وريدي ساعة 24 / الوزن ضعف ساعة 24

10/ مجم 500سم

سيفترايكزون100 mg / kg / day

9

oral

عمل بعدGastric wash

ساعة 24

(once)

5/ مجم 100 سم

/ مجم 200 أو سم5

زيسروماكس( macrolides )

10 mg / kg / day

10

- Given for 3 – 5 day only & oral as it accumulates in tissue

37

- Used for atypical infection

وريدي ساعات 8 X 1.5 الوزن -ساعات 8 كل

قده يضاف -5جلوكوز %

100/ مجم 500سم

فالجيل7.5 mg / kg / dose

11

- Given against anaerobes & with glucose 5 % same amount

- Given post vent ( anerobic infection ) + in sepsis + in NEC

وريدي ساعة 24( once )

قده يعطى جلوكوز % 5

سم 1/ مجم 2 ديفلوكان( nystatin )

6 mg / kg / day or dose

12

Anti fungal >

حاله لو Vent أيام 7 من أكترSepsis – resistant sepsis – NEC

وريدي ساعة 12 / الوزن نفس ساعة 12

10/ مجم 500سم

ماكسبيم100 mg / kg / day

الفورتم زي

13

وريدي ساعات 6 ( 4الوزن/ ) Vial / 10 سمVial =1000000 IU

مائي بنسلين100,000 IU / KG / day

الـ وفي

CNS infection

200,000 : 300,000 IU/kg /day

14

38

Infusion

محاليل علىالدم

- renal dose

شرطة 18كيلو لكل

- cardiac

شرطة 36كيلو لكل

سم 5/ مجم 200 دوبامين-Renal dose : 5 micro /

kg / min

-Cardiac dose : 10 micro / kg / min

15 ل نوصل ممكنإلى وتؤدى

V.C dose in (Severe hypotension,septic

shock )

15

N.B.

- acts mainly on heart for ( hypotension , hypoperfusion , brady < 100 + good sat )

- withdrawal gradually

- if HR > 150 >>> don’t give cardiac dose

- dopamine VC dose ( 15 ) in hypotension

- given to improve perfusion > (( How to know defective perfusion ? ))

>> mottling ( indicate decreased perfusion & acidosis “hypoxia” ) +

>> Pallor

---- test of perfusion >>

اللون رجوع درجة وشوف.. سيبه ثم 3 و 2 و 1 الصدر على اضغطالدواء هذا حساب كيفية لفهم

wt (?) X dose (5) X dil. (5) X 24 X 60 (min) / conc ( 200) X 1000 (micro)

أسهل طريقة

واضرب عادي احسب X 1.44 هو اللي (24 X 60 ) / 1000

محاليل علىالدم

احسب بالمعادلة

سم 5/ مجم 250 دوبتركسRenal : 5 micro / kg /

16

39

العاديه واضرب

1044 في

20/ مجم 250 أوسم

min

Cardiac : 10 micro / kg / min

- Act on blood vessel mainly esp. pul. Vs. so improve asphyxia

- Usually , more than dopamine by 5 (not givin alone )

- Withdraw gradually

ثم عادي احسب: للتسهيل X 1.44

** Relations between Dopamine & Doptrex **

- both +ve inotropic

- doptrex decrease tachy. Produced by dopamine

- Both withdraw gradually

وريدي ساعة 12 وزن نفس / الطفل

ساعة 12بالـ وتحسب

سمهتدي ولو

1mg / kg / day

يبقىوزن نصف

/ الطفل ساعة 12

سم 1/ مجم 100

ملح محلول ) 9 + 1 )

سم 1 أن معناه مجم 10 فيهفي سم 1 وبنحل

من سم 1 يبقى 10 مجم 1 فيه للالمح هنحسب الي وده

عليه

الزكس1mg / kg / dose

17

- Given in cardiac – hydrocephalus – IC He – HTN – after plasma & blood

وريدي ساعة 12 سم 1/ مجم 4

م. م ( 9 + 1 )0.4 >< سم 1 لو

( ديكادرون) ديكسا

0.15 mg / kg / dose

But :0.25 mg / kg / dose

18

40

1بيقول) البعض غلط لكن( 3+

In off vent. & severe pneumonia

- In off vent. Give dexa for 24 hr. before off so 2 doses

Function : decrease laryngeal edema due to ETT

Also in brain edema , allergy -

Allergy > anaphylactic shock & skin rash

- Also in MAS > for chemical pneumonitis

وريدي ساعة 12 الناتج يقسم 2 علىكل علشان

ساعة 12

سم 1/ مجم 25

م. م ( 9 + 1 )

>< سم 1 لذا مجم2.5

زانتاك2 mg / kg / day

19

- Some say it is given in all cases till reach full amount

But its indications are :-

جاب لو Green , brown residual with open ryle

Or when take Lasix (cause stress gastric ulcer)

Contraindicated in sepsis(as the gastric acid is the ist line of defence)-

وريدي ببطء

ساعات 6 الوزن نفس+ كالسيوم

الوزن نفس5 جلوكوز %

نفس يعطى5 جلوكوز الكمية

%

كالسيوم1 cc / kg / dose

20

يعمل ألنه شديد ببطء يعطى - brady

( كاربونات كالسيوم بيرسب عشان ) مع يعطى ال - Na bicarb

الكانيوال بره طلع لو Cautinous. necrosis بيعمل -

حاالت في إال يوم تاني من يعطى - DM , preterm , hypoxia

رضاعة ساعات 3/ سم 15 لـ يوصل لما بيتشال -

41

أو سرية قسطرة في يؤخذ ال - CVP ( central line )

ال حاالت فى الجرعة double يعطى – Hypo Ca

وريديشديد ببطء

أوIM

كل يوم أول ساعة 12

كده بعد لوساعة 24 كل

وزن نفس24 كل الطفل 12 – 8 أو

ساعة 2 على تقسم على 1 أو

حسب

10 >< ملم 1مجمم. م ( 9 + 1 )

1 >< ملم 1 لذامجم

كوناكيون1 cc / kg / day

(vit K1.)

فيه لو كده بعد ونزودReddish sec. by ryle

21

لو فقط يوم ألول يعطى غالبا - FT لو يوم لتاني نزود ممكن و preterm يوم تالت أوأو نزيف فيه لو - gastritis كابرون+ ساعة 12 كل وريدي األمبول نصف ممكن برده يعطى +

البالزما+ دايسنونوريدي ساعة 12 ــ ــ ودايسنون كابرون

ساعة 12/ أمبول 0.2522

الـ في الكوناكيون مع يعطى Active bleeding

Iv slow or per oral

أو ساعة 12 ساعة 24

2 على تقسم سم 2/ مجم 101 + 9

>< سم 1 لذا مجم 0.5

برمبرام) 0.3 mg / kg / day

0.5 وليس )

االحسن بتقول ناس Cortigen B6 سم نصف

مشاكل علشان عضل( البرمبرام

23

حاالت في يعطى -Vomiting , colic ( cry ) , bring leg to abdomen

- side effects : extrapyramidal if overdose so give cortigen b6

42

أو بالفمالرايل

ساعات 8 كل وقبل الرضاعة

ساعة بربع

ــ ــ سيميسكيونساعات 8/ نقط 5

24

Given in distention

الرضاعة حاالت كل في واألحسن prophylaxis

أو بالفمالرايل

ساعات 8 وقبل

ب الرضاعةساعة بربع

الوزن 1/3 8 كل بالفم

ساعات

ــ موتيليم= ميتونورم1.5 cc / kg / day

25

للرضاعة فات اللي مع

وريدي M الـساعات 8 كل

الناتج تقسم ال سم 1/ مجم 25

م. م ( 9 + 1 )

سم 1 الـ يبقى , مجم 2.5 فيه

كام نحسب ونقسم مجم

او2.5 على استخدم

في الوسطينطرفين

أمينوفيلينLoading : 5 mg / kg / dose

Maintenance : 2 mg / kg / dose ( every 8 hr. )

26

- it's bronchodilator + respiratory stimulant

بعد يعطى ( post-vent )

+ apnea + preterm + post CPAP

حاالت وفي chest

Side effect :arrhythmia which is not present in caffine citrate (another R.stimulant)

وريدي

12 ساعةM لل

الـL = 1.5 cc / kgالـM (if 5mg / dose ) =

40 1مجم /

سم( 1 + 3 )

م . م

سومينوليتاphenobarbLoading : 15-20 mg / kg / doseMaintenanc

27

43

Weight /4 every 12 hrs

سم > 1مجم 10

e : 5 mg(3-8) / kg / dose

ساعة 12كل - given in ventillated pt. + in convulsions- it's a sedative drug + gradual wuthdrawal 8 - 5 - 3

الـ حاالت إلى convulsions في نوصل يكون 8ممكن السحب وعند Gradual 8 - 6 - 4 - Also it is atreatment for jaundice (phenobarb)>>enzyme inducer

على المحاليل

الـMعلى المحاليل

L الـ10 - 20 شرطة

كيلو لكلM الـ1.2 - 2.4 شرطة

كيلو لكلسرنجة )األنسولين)اقسم - اوالوزن

10علي ) 1.لو( 20وعلي

.لو (وعلي)05 5) )2.لو

مجم / 5سم 1

( 1 + 4 ) م . م 1لذا

فيه سممجم (1

10 شرطة )

دورميكم(midazolam )Loading : 0.1 - 0.2 mg / kg / doseMaintenance : 0.05 - 0.1 or 0.2 mg / kg / hr^اضرب x 24 البسط

28

It's ms relaxant--Given in vent. ptمشاكل - بدون فجأة يوقف -ممكن

وريدي

shots 15 شرطة / ) كيلوsafer )

+1لو 9<<<<<

+1لو 4<<<<<

بافلونش اااااابال

علشان يستخدخطر

العيل م لو

29

44

7 شرطة / كيلو

مش ماناعلي خالص

فاتوا الي- Keep your eyes on O2 sat. as it cause Hypotension - cardiac arrest - respiratory arrest

اتسدت األنبوبة هيموت ولوبـ - الواد لو الـ fight يؤخذ سومنوليتا IMV مع أو دورميكم ومفيش

وريدي

12 ساعة

50 1مجم /

سم( 1 + 4 )

ال 1لذا فيه سم

مجم 10

ايبانيوتينL = 15 mg / kg / doseM = 5 mg / kg / dose

30

- Anticonvulsant used when someniletta Reach 8 & no responceويكون معاه سومنوليتا ندي و 12وساعتها واإليبانيوتين 12الصبح 6و 6بالليل

Adrenaline ( epinephrine )- in bradycardia or CPR or hypotension or acute CVS collapse

- dilute in 9 cm ( 1 + 9 )- Dose :- 0.1 – 0.3 ml/kg/dose ( of 1/10000 conc. Iv bolus ) if bolus over 3-5 minutes ( or endotracheal tube followed immediately by 1ml normal saline )

- given every 3 minutes up to 3 times - If no response give >> concentrated (not diluted) in ETT >> 0.3 – 1

ml/kg/dose(usually 1 cm )- infusion : start at 0.1 mg/kg/min and adjust to desired response to a

maximum of 1mg/kg/min - infusion done practically by giving 1cm of concentrated adrenaline on

23cm glucose given by a rate of 1cm/hr - Preparation :- 1mg/1ml ampule >> 1 + 9 D 5% or normal saline So, 0.1

mg/1ml = 1/10000- VIP :- if infant enter in bradycardia more and more >> adrenaline infusion

31

Lanoxin ( digoxin )- 0.01 -0.05 mg/kg/day

- ampule ( 0.5 mg / 2ml )

32

45

- Loading and maintenance doses :acc. To age (see ur text) - For HF & HTN

- not given if HR less than 100- not given directly after Ca

Oral drugs

A) oral antibiotics :- oral or by Ryle

when to you use :

1- Body with pneumonia or sepsis , you will discharge him &want to complete the course.

2- If no Canula is present.

e.g :-

1- Unasyn >> 25-50 mg/kg/day >> half of weight / 12 h

Every 12 hrs , oral (Dilution = 250 / 5 cm )

2- ximacef >> 8 mg/kg/day , (oral 3rd generations)

Every 12 hrs (conc. = 100/5 cm)

3-Zithromax >> 10 – 15 ml/ kg/day

Once every 24 hrs , oral (conc.= 100/5 cm)

-Ursogol >> 1cm /kg/day , In Direct jaundice (cholagouge)

- Cholestran >> 2cm/kg/dose every 12 h , ( sach. / 10cm glucose 5% ) (in direct Jaundice as bile acid sequestrant)

46

Tablet drug ( taken oral or by Ryle )

1- Sildinafel >> 1 mg/kg/dose ( Virecta )

every 8 - 12 hrs Tab is 100 mg

dil of does: ½ tab on 10 cm of sterile water (50 mg = 10 cm) (5 mg = 1 cm )

(taken by Ryle )

2- Lovear (Antiviral) see before

3- capoten 25 mg (Tab) for HTN >> 0.1- 0.4 mg/kg/does

بالرايل الرضاعة قبل ساعات 6/ ويعطى مقطر ماء سم 10+ قرص ½ 4- Folic acid

ساعة 24/ شرطة 40 % )0.2 سم 10 مع ويذاب طحني قرص نصف: اسيد فوليك بالفم(

بالفم قطارة : - Others

-Baby - vit / poly vit = 5 drops / 24 hs

ساعة 24/ نقط 5 قطارة: دروب في( نريهيدروف حديد ساعة 24/ نقط 5قطارة: )

فورت الكتيول

بالفم ساعات 12 –8 كل سم 1 ويعطى مقطر ماء سم 5 فى يحل كيس - -

- Lactobacillus stimulating factor ,thus increase immunity

- given in PT as prophylaxix against NEC + gain weight

L-Carnitine

- 5 drops/24hours

Cetal drops

47

- 2 drops/kg/dose /6hours

For Gaining weight

- Adjust feeding for suppying infant with 120-150 Kcal / kg

- Drugs >>

هيدروفورين و اسيد فولد و دروب فى و فيت وبولى كارنيتين ال و فورت الكتويل الذرة زيت و

Ointements

Thrombophob :- for contusion & sites of canula

Fucidin :- Antibiotic

Muconaz gel

- for oral fungal infection

- gel for mouth & tongue every 6 hours

- done with mouth wash by bicarbonate

الجلسات

Uses :

1 وفاركولين أدرينالين جلسات - Post-vent >>>

2 أتروفيت و فاركولين جلسات - chest problems >>>

الفاركولين جلسات

48

أو) ميكوسولفات نقط 5) + - ( ملح محلول سم 1.5فاركولين+ نقط 5: التحضير عشان( secretion أمبيروكسول

فاركولين كيلو/ نقطة 2: الصحالحالة حسب على ساعة 12 أو 6 أو 3 كل: التكرار

function : bronchodilator + decrease secretion ( salbutamol B2 agonist )

< األدرينالين جلسات

function: post vent > decrease vocal cord inflammation(vasoconstrictor)

( التخفيف ده) ملح سم 9 على أدرينالين سم 1: التحضير

ملح سم 1.5+ محلل أدرينالين سم 0.5 منهم نأخذساعات 3 كل الفاركولين مع بالتبادل جلسات 3: التكرار

الـ نمنع علشان وهكذا فاركولين وراها واللي أدرينالين جلسة يعني V.C. 3 و بس جلسات

< األتروفيت جلسات

function: decrease secretion & in wheezy chest ( as bronchodilator ) , it is ipratropium bromide

األتروبين مشتقات منملح محلول 1.5+ نقط 5: التحضيرفاركولين والباقي( اليوم في مرتين ) 8 أو ساعة 12 كل: التكرار

الملخصالـ عيان -1 chest معاه زود استجابة مفيش ولو تشوف ما زي فاركولين أدي

في خاصة األتروفيت pneumonia

ويوقف الفاركولين مع بالتبادل أدرينالين جلسات post vent ... 3 عيان -2بعدها األدرينالين

الـ لو -3 chest ميكوسولفان زود وحش

49

الجيد التشفيط تنسى وال -4

.pulm. cort جلسات

long acting bechlomethazone (inhaler )

لـ مناسب غير neonateواألحسن atrovent الـ بيزود ألنه chest infection

IMV & CPAP- Better read Sayed & Helmy for mechanical ventilation

weaning from IMV :

1- Indications :

1 - Fio2 < 40 %

2- PIP > 15 cm h2o or less

3- low VR

4- stable HR & BL. Pr. & o2 saturation

5- ABG acceptable

-- when to off

1- CXR >>> good

2- ABG >>> good

3- clinical :R. rate < 40 , colour , auscultation

2- method : (start by cessation of dormicum &gradual cessation of somineletta )

1- decrease setting very gradual either FIO2 - PIP - VR - EEP till previous values

50

2- put on endo tracheal CPAP (maximum 2 hours to avoid pulm.collapse) then on CPAP or nasal ( extubation )

3- keep o2 sat. normal ( 90 - 95 )

4- may put on assisted AIC for spontanous breathing + decrease dormicum & somineletta)

3- Dexa :- before stopping by 24 hours ( 2 doses ) (( why > laryngeal edema ))

4- post. vent

بادرينالين وابدأ ساعات 3/ فاركولين مع بالتبادل أدرينالين جلسات 3

5- aminophyline > respiratory stimulant + bronchodilator > when indicated

6- Flagyl >> for Anerobes and diflucan for fungi

الـ على تحكم ال:- ملحوظة sepsis بـ hypo activity واخد واد في sedation,

! إيه؟ على قف هن طب

على نقف يقول البعض CPAP bubble على نقف يقول والبعض ETT CPAP ساعتين لو أنه مالحظة مع األخير الرأي واألفضل nasal ثم testكـ preterm عنده ولسه retraction على فنقف CPAP bubble الـ نقلل عشان work of breathing

الـ:- ملحوظة ETT CPAP بيعمل عشان ساعة 2 من أكثر يوضع ال lung collapse

ARTERIAL BLOOD GASES )ABG(

51

1 ) NORMAL FINDINGS :

PH : 7.35 – 7.45 OR 7.40

PO2 : 60 mmHg ( after clamping umbilical cord )

PCO2 : 35 – 45 mmHg

HCO3 : 18—22 mmol / L or 20 – 26 mEq / L

BASE DIFICIT : BE (- ) = +2 : -2

2 ) INDICATION :

1 – RD esp .(if PRETERM )

2 – SEPSIS eg . pneumonia

3 – severe diarrhea and vomiting

4 – DKA

5 – RENAL PROBLEM

6 – ANEMIA

3 ) CASES WE FACE :

1 – RESPIRATORY ACIDOSIS

2 – METABOLIC ACIDOSIS

3 – MIXED RESPIRATORY AND METABOLIC ACIDOSIS

** alkalosis is uncommon and usually is iatrogenic

NB : higher PH limits is desirable in the prescence of hyperbilirubinemia since

acidosis esp. respiratory may potentiate encephalopathy .

4) COMPLICATION OF MARKED ACIDOSIS :

1 – increase pulmonary vascular resistance .

2 – inhibition of surfactant synthesis .

3 – impaired myocardial contractility

52

4 – impaired diaphragmatic contraction

5 – impaired renal excretion of acid

CAUSES OF RESP ACIDOSIS

5 ) CAUSES OF METABOLIC ACIDOSIS

- Asphyxia- Apnea

- obstructed ETT - bronchospasm- pulm. Edema

- central hypoventilation- Chronic lung disease

1 - hypoxia2 – shock and hypoperfusion

( sepsis,HF ,NEC)3 – inborn error of metabolism

4 –RTA5 – feeding acidosis in premature

6 ) HOW TO INTERPRET ABG: >>>>>> LOOK AT PH

ACIDOSISALKALOSIS

HCO3PCO2HCO3PCO2

IF LOWIF HIGHIF HIGHIF LOW

METABOLIC ACID

RESPIRATORY ACID

METABOLIC ALK.

RESPIRATORY ALK.

** MIXED RESP. AND METAB . ACIDOSIS **

مايسمى نحسب.... قليل هيكون PH طبعا <<< EXPECTED PCO2 <<< = ( HCO3 ×2 ) + 8

ثالثه من حاجه هيكون الناتج :

التقرير فى اللى PCO2 مساوى – 1 ( PURE METABOLIC ACIDOSIS )

منه اعلى – 1 ...... MIXED ( CO2 retention )

منه اقل – 3 ............ normal ) COMPENSATED ( if PH

53

7 ) WHEN TO COMPENSATE by bicarb ??

If 2 or more of these criteria :

1 – PH ≤ 7.25

2 – HCO3 ≤ 12 mEq / L

3 – BASE DIFICIT ˃ -10

8 ) N.B

ال على واالخير االول االعتماد CLINICAL التقرير من اكثر

As bicarb is acalculated data ( there is no electrode that measure bicarb but the computer calculate it from PCO2 , PH

ال فى علط الجهاز فلو PH و PCO2 , غلط التقرير كل

9 ) MANAGEMENT :

1 – RESP. ACIDOSIS

ventilatedIf unventilated

Causes >> ETT block , ETT dislodged , pneumothorax

mostly due to Respiratory failure

- Reintubatesuction and aspirate -

- increase rate & decrease time

Intubate and ventilate or CPAP

2 – METABLOIC ACIDOSIS

if failed … ventilation

give more antibiotics for (sepsis )

Correct bicarb ( criteria )

3 – MIXED CASES

54

1 – don't give bicarb ist as it will give co2 inside the body(practically we give it together with increasing co2 wash)

2 – correct resp. acidosis 1st by increasing vent . rate 3 – then give bicarb

4 – also decrease inspiratory time if good expansion to increase expiratory time to wash co2

10 ) HOW TO CORRECT HCO3 :

A – EMERGENCY CORRECTION : ( if there is no ABG )

In case of acetotic breathing ( rapid deep ) give :

الطفل وزن bicarb + شديد ببطئ ويعطى % 5 جلوكوز الكميه نفس

B - USUAL CORRECTION :

بال اوال نبدا half correction لل المجال لترك kidney ندى وممكن الباقى تكمل total لو severe + sepsis

So we give : body wt (kg ) × base deficit × .3

2

دقيقه 30 – 15 على شديد ببطئ ويعطى % 5 جلوكوز الكميه نفس+ الناتج ويعطى

N.B maximum dose : 10 Na bicarb

ساعه نصف بينهم 2 تقسمها او 10 من اكثر ماتديش طلعت المعادله مهما .... يعنى

- Some give maintenance of bicarb is 1 ml / kg / dose/12 h slow IV but it isn't

preferred

11) INFORMATION ABOUT BICARBONATE

- Na bicarb 8.4 % conc. Per ampule55

- Dilute 1:1 with glucose 5% not Ringer lactate

- Bicarb should be given very slowly to prevent rapid increase of osmolarity which may lead to IV hge . - Bicarb should be given in good acting peripheral vein ( irritant ) - Never infuse Ca with it to prevent form of ( Ca Carbonate ) - Don't dilute with saline ( increase sodium level and increase osmolarity )

12) ANION GAP :

Def :- The amount of uncalculated cations which if added to calculated cations can conteract anions

المعادلة(Na + K ) – ( Cl + HCO3 )

It is arrange between 8 : 16 mEq/l

Important in cases of metabolic acidosis

Metabolic acidosis With increased gap

metabolic acidosis With normal anion gap

-- Cause :- increased acids-- E.g :- RF

DKA-- Corrected by HCO3

-- Cause :- loss of alkali -- E,g :- diarrhea

- RTA-- Not corrected by HCO3

13) EXCESS HEPARIN may give false metabolic acidosis Repeat test if the result is suspicious Extreme hypothermia lead to false increase PO2 Extreme hyperthermia lead to false decrease PO2

NB :- Sample of ABG should taken arterial , but some take it venous ,

so PO2 isn't important finding in the report to judge

NB :- Ringrer lactate

الى الجسم داخل يتحول Bicarb ال حل فى يستخدم ال لكن لوحده أعطى لو ولكن Bicarb

56

Signs of Preterm and Full term

مش :- األهل لو الوالدة بميعاد تطلع متقدرشى ممكن المرضى التاريخ من ألن األهميةوعارفين منتبهين

POST TERM > 42 W

PRETERM < 37 WFULL TERM > 37 – 42 W

Very PT has no creases and increase

by time

Crease is completeSOLE

Male : undescended testis

Skin without rugue Pigmentation

Female : small labia majora

Prominent clitoris

العكس

العكس

Genitalia

Faint areola No bud or nipple

PresentNipple

Thin No cartilage , No

recoil

NormalEar

Thin – red – apparent veins

Thick – no veinsSkin

Fine hairNoLanugo hair

التذاكر فى مالحظات

المحاليل : اوال1 – 1st day glucose 10 % or 7.5

2 – 2nd day neoment + rest or add +Ca3- you can add aminovein from 3rd day & written with solutions

اللى -4 مش كله اليوم فى اللى الجرعة تحسب انك االدويه تخصيم فى التنسىالجرعة × 12كل احسب والكالسيوم الكالسيوم( + ) × ...... 4ساعه الجلوكوز

457

على -5 المحاليل المعدل ( )24اقسم الريت عشان ساعهحالة -6 عند صفراءلو مش أصال ..... ديسترس ريسبايراتورىه والواد محاليل ماتديش

7 - increase by 10 ml / day till 150

االدويه : ثانياكمان (1) يوم تانى وممكن كوناكيون يوم اول

الحيوية (2) للمضادات اختيار اول وامكين يوناسينفيها (3) المستخدم لأليام ترقيما الحيوية اكتب جانبيه المضادات اثار لها التى

امتى تعرف من توقفهم عشان اكتر استخدم ولو االميكين يوريا , 7مثل نعمل ايام وكرياتنين

Write with drugs that have loading and maintince >> L , M (4) Preterm , asphyxia , IDM) ال ماعدا يوم ثانى من يدخل 5الكالسيوم )

الجرعات عدد على اليوم نقس ال Total doseفى ال تنسى )6( مAminophyline ………….. after vent and for premature (7)

Gradual) بينسحب النه الدوبامين من بالك 8 خد )

: الرضاعه ثالثا

شيل ساعات 3 كل سم 15 ل الوصول وعند االمبينوفيلين شيل -1 Ca

المحاليل شيل ساعات 3 كل سم 20ل الوصول عند -2

الحاجه حسب الرضاعه فهنا ساعات 3 كل سم 30ل الوصول عند -3

سايميسيكون و موتينورم..... المعتادة االدوية الرضاعة مع -4عنده اللى -5 jaundice ساعات 3 او 2 كل الرضاعه

58

االطفال استالم بعد الشفت في تفعل ماذا

واستوفي االهل علي الرد وفي التشخيص في يساعدك انه بحيث حاله لكل شيت اعمليلي ما فيه

- Day in unit/Days of the baby (age)

- History

- O2(type of O2 used now)

- phototherapy + its investigations(TSB & DSB)

- RR in one minute

- feeding (Ryle or suckling – residual – amount- ….. )

- Examination

** general **

*Colors ( pallor , jaundice , cyanosis , mottling , capillary refill )

*activity

*temp

*BP

*Weight

** chest **

*Auscultate :- air entry + additional sounds

59

** Heart **

*S1 , S2

*HR

** Abdomen **

*Distension – HSM

** Investigations **

*CXR – RBS-ABG

** Recommindations **

االستشاري بيزودها الي والحاجات يتشال او ينضاف شايفه انت الي

Follow up ( During Shift )

- RR - Color -Saturation - Feeding - HR - In IMV >> auscultate Tube

االطفال استالم بعد الشفت في هامه مالحظات

1 – check temp of incubators2 – if photo :

*check fluids ( rest/ add)*distance – numbers of lampsالرابطة ... * و الحجم النظارة

3 – O2 :*nasal : fitted or not* CPAP :1- Percentage ?? >> if more 70 % and the neonate still unstable shift to IMV2- tube >> hear , aspirate* IMV : - setting - FiO2 …. Decrease gradually if there is improvement - Tube …. If obstructed , change

60

- auscultate chest4- Solutions

Check rate – type of solutionRest / add – aminovein

5 –feeding : distension – vomit6- drugs :

هتتغير لو AB شوفهتضيف او حاجه - هتوقف

Dopamine HR7- investigation : done or not 8- chest examination >>>>> apnea , preterm9 – abdominal examination10 – vitals11 – special care for each case12- Ekteb El-tazaker13- detect Jaundice14- Detect pallor (( Pallor + jaundice = hemolysis ))

التمريضية العنايه

ح . . / ع ساعات3م -كل - حيويه عالمات ساعات 3متابعه

كل - وسكر ضغط ساعه 12قياسالتسمم - لمنع السره على غيار

فوتو - على لو التناسليه واالعضاء العين على غطاءمعدل : – - - زياده ترجيع انتفاخ حدوث مالحظه مع التغذيه فى

التنفسثرومبوتوب : - ومره هيموكالر مره الكانيوال مكان فى

فيوسيدين : - بيحمر اللى اللصق مكان فىالحنجريه - باالنبوبه عنايهالسريه - باالستره عنايه

الكدمات - على هيموكالر دهان

RESPIRATORY DISTRESS

61

- Respiratory problems are the commonest cause of serious neonatal illness of death

GRADES :

Grade 1 : tachypnea ( RR ˃ 60 Br / min )

Grade 2 : retraction + grade 1

Grade 3 : grunting + grade 2

Grade 4 : cyanosis + grade 3

CAUSES :

1) RESPIRATORY : respiratory distress syndrome – MAS – pneumonia - pneumothorax – airway obstruction as Bil . choanal atresia - bronchopulmonary dysplasia2) CARDIAC : HF – PDA – PP HTN 3) CENTRAL : HIE – IC Hge – meningitis4) HEMATOLOGICAL : severe anemia – polycythemia 5) OTHERS : sepsis – hypoglycemia – metabolic acidosis - hyper / hypothermia – D hernia

APROACH TO DIAGNOSE : A ) HISTORY : 1)PRENATAL : any disease of the mother befor birth leading to hypoxia , Maternal drugs , previous baby with RD 2) NATAL : PROM – fetal distress – obstructed labor – AF (meconium staining ) 3) POSTNATAL : APGAR – resuscitation –time of RD – TTT Given

B) EXAMINATION : 1) Grades 2) chest auscultation

Grades :Grade 1 : tachypnea ˃ 60 Br / minGrade 2 :retractions ( interscostal – subcostal –suprasternal )nasal flaring which represent attempt to decrease airway resistance(air hunger)+ pursing of lipsGrade 3 : GRUNTING :- ( better by stethoscope ) >> Forced expiration against closed glottis . Why ? … to produce +ve end expiratory pressure (PEEP) that keep the small airway opened and improve distribution of ventilation .Grade 4 : CYANOSIS ………. IMV or ambu + mask or ETT 1st you should know if central >> lips , tongue , mucus membrane

62

Or peripheral (acrocyanosis) >> hands , feet Also see pallor >>>> shock – anemia – HF – V.C Examination >>> abd – chest – Heart – genitalia Take care of stridor ( large airway obstruction )

C) INVESTIGATION : 1) Chest x-ray : may find : opacity " pneumonia " MAS – Ground glass opacity HMD: white lung 2) ABG… routine 3) CBC – HB- HCT – CRP 4) ECHO

D) Monitor the PT 1-RESPIRATORY :RR – apnea – cyanosis – chest movement –auscaltation – o2 saturation 2 – CARDIAC : HR – BP – pallor – anemia 3 – activity sepsis 4 – investigation 5 – change position ( ventilation ) – suction 6 – physiotherapy

Respiratory disress syndrome )HMD(- Common disease caused by surfactant deficiency

- CAUSES : 1- prematurity especially ˂ 32 wk 2 – prenatal asphaxia

3- IDM 4 – C.S

- Decrease INCIDENCE nowadays due to : 1 – prenatal steroids 2 – surfactant injection by ETT- DIAGNOSIS : History : as usual esp . prematurity – DM – C.S – acute partum hge – male sex CP : RD …. Rate ˃ 60 – retraction – cyanosis within 1st 4hours after birth and progress over 1st 48 – 96 hrs of life then begin to resolve spontaneously - apnea from 2nd day

EXAMINATION : RDS grades , Breath sounds decrease bilaterally + crepitation , Pallor + edema

INVESTIGATION :1) XRAY : grades :- Grade 1 :fine reticulogranules mottling + good lung exp. Grade 2 : mottling ( ground glass app ) + air bronchogram

63

Grade 3 : diffuse mottling and increase air bronchogram Grade 4 : white lung

NB:- white lung >>is a term in CXR >>it indicates RDS in PT (preterm) ,

If it's found in a full term suspect congenital pneumonia

2) ABG 3) RBS4) CBC – CRP – CULTURE – SEPSIS WORK UP5) ECHO PDA

- PROBLEMS AND HOW TO MANAGE :1) HYPOXIA : ( PAO2 normally ˃ 70% ) by ABG - Keep SPO2 bet. 90 – 95 % by oximeter - Use head box or nasal ( grade 1 – 2 ) - CPAP in grade 3 ( also if PAO2 ˂60% OR in apnea ) - If grade 4 >> IMV 2) HYPERCAPNIA AND RESPIRATORY ACIDOSIS : - CO2 is more diffusible than O2 so hypoxia appear before hypercapnea - PACO2 is normally bet ( 35-45) - So do : good suction.. do ABG and manage( If PCO2 reach 60 IMV)

** Specific therapy to HMD :- Surfactant injection but expensive- Prophylactic CPAP has arole here ??! - IMV early intubation leads to early extubation Indication : - PH ˂ 7.2 PCO2 ˃ 60 PO2 ˂ 50

- sitting :- FiO2 90 , VR 40-60 , time 0.36 , PIP 20 : 22 , PEEP 3-4 , Flow 8-10 L/m2 (( decreased Inspiratory time + increased VR to manage respiratory acidosis ))

3) FLUIDS & ELECTROLYTES : do 20 % rest as increased fluids >> pulmonary edema - hypoglycemia bolus Dextrose 10% 4 ml / kg then maintince 6mg/ kg / min4) FEEDING 5) CIRCULATION inotropics – blood – plasma 6) INFECTION AB7) TEMPERATURE 8) APNEA esp . on prematures and on 2nd day9) IC Hge10) NURSING

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11) MONITORING

NB :- Heart failure in neonates is diagnosed by >> tachycardia , liver enlarged

Broncho-pulmonary dysplasia ) BPD (

Def. : is a neonatal form of chronic pulmonary disorders that that follows a primary course of respiratory failure ,e.g. RDs - MAS in the 1st day of life . also defined as persistence O2 dependency up to 28 days .

Incidence : is more in ELBW infant < 1000 gm

Risk factors and causes : 1- IMV هــام , volutrauma / barotrauma2- Inflammation 3- Prolonged O2 exposure 150 > هـــام hr by > 60 % 4- Prematurity , white race , males , tracheal colonization with ureaplasma ,

ELBW , sepsis .

Pathology : ↑↑ O2 → proliferation of type II alveolar cells and fibroblast → alternation in surfactant system → increase inflammatory cells , cytokines & collagen .

C\P : - Infant with progressive deterioration in pulmonary function , requiring

IMV beyond 1st week of life , poor growth , pulmonary edema , apnea , bradycardia

- Examination : retractions , rules ??? , wheezes , hepatomegaly .- Investigation :

1- ABG & electrolytes .2- Urine analysis . 3- CXR : diffuse haziness , lung hypoinflation, streaky markings , patchy

atelectasis , intermingled with cystic area , may lung hyperinflation . 4- Renal U\S , Echo .

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Management : The most effective solution is prevention of BPD by :1- TTT of prematurity , RDs , antenatal steroid .2- Decreases risk factors by ↓ O2 exposure , early surfactant + early CPAP

and avoid IMV .3- Vit A .4- Caffie - nitric oxide?

Treatment : 1- Respiratory support : maintain supplied O2 bet. 90% to 99% .2- Improve lung functions :

- Fluid restriction- diuretics therapy as lasix to decrease pulmonary edema .- bronchodilator as B2 agonist & theiophyline أمينوفيلين .

3- corticosteroid as Dexa .4- Growth & nutrition 120 – 150 ?? \ day

NB : the most important three lines in ttt of BPD are: 1- steroids 2- aminophyline 3- lasix

Meconium aspiration syndrome

Factors that ↑ risk : 1- Amount ↑2- Thickness3- Duration4- Complications

Usually MAS occur in mature baby , if premature → suggest listeria infection or bilious reflex 2ry to intestinal obstruction .

Types of meconium :1- Thin 2- thick

Complications : 1- Thin meconium → aspiration by the baby → chemical pneumanitis → 2ry

bacterial infection → bacterial pneumonia 2- Thick meconium → aspiration

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- Airway obstruction which may be :Complete → cause lung collapseOr Partial → cause 1 way valve → lung hyperinflation → air leak & spontaneous pneumothorax .

- Chemical pneumanitis .- PPHTN ( persistence pulmonary HTN ) .

Now how to Diagnose : 1- History : obstetric history of meconium stained labor + history of fetal

distress .

2- Examination :- Skin , nail , umbilical cord → meconium stained- Lung over distention + bowing of sternum ( ↑ AP diameter )- Auscultation → Ronchi + Crepitation

3- CXR :- Over expansion – multiple atelectesis- Opacity → pneumonia - Pneumothorax , pneumomediastinum

4- Lab . : ABG5- Echo : for PPHTN

* Treatment

A) Prophylactic : Better & recommended

When head is delivered and before respiration stimulation → suction of mouth (1st)and nose very well &wrap baby with heated towel to prevent

respiration and intubate &suction of trachea +O2

B) Curative : TTT of problems

1 ساعتين كل صدره اسمع )) Respiratory distress :

-humid o2 according to case with saturation >95%

-↓ humidity

-endotracheal شفط ←

-UAC for regular ABG

-If severe case → IMV & setting is : Fio2 (80:100%) , VR:60

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, PIP : 20-220 or ↑ PEEB :3 ( العادى عن قليل ) + ↑ expiration

time , make inspire 3

-early surfactant → cause P.HTN , P.hge

2)) IVF & Feeding

-start low level fluid 60/kg D10% 1st day &↑ gradually

-RBS + serum electrolytes

-feeding gradually 1st by ryle tube

3)) Infection

- All infants give broad spectrum Abs

- Change acc. To culture

- Start with Tripple

4)) Pneumothorax 15%

- Diagnose: deterioration of condition ,cyanosis, ↓ air entry +unequal ,

CXR

- TTT:emergent butter fly then chest tube

5)) PPHTN

- virecta , Dopamine to ↑ systolic bp

6)) HIE

7)) No rule of steroids الكتب كالم ده ( but Dexa better to be given due to

chemical pneumonitis )

8)) Strict nurse care (position , suction , CPT , ABC regular)

Transient Tachypnea of Neonate )TTN(

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-It is due to delayed clearance of fetal lung fluid as fetus in intrauterine life → lung filled with AF → during normal labor baby is squeezed in birth canal →squeeze AF from lung → AF absorbed through lymphatics

-Other names

Wet lung – type 2 RDS

- It is common and resolve whithin 3:5 days (self-limited )

-Risk factors

- C.S &term baby

- maternal sedation ---delayed clamping of cord

- Prematurity -maternal asthma -polycythemia

-Diagnosis

1- History

-Gestational age -Type of delivery C.S -maternal sedation

- onset of distress( within 1-2 hrs after birth ) -Breech - maternal asthma

** The usual presentation is ** : Term infant delivered by C.S , shortly

after delivery has tachypnea up to 100-120 br/min & last for 1-5 days

2- Examination

-RR > 100-120 - Grunting - Retraction - Cyanosis by corrected easily

-Barrel chest

3-CXR : (NO) HMD (ground glass appearance )

-the hallmark is : hyper-expansion of lung -prominent pulm. Vascular marking

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4- ABG :

- Hypxia , Hypercapnia , R. acidosis

-Management

1- Hypoxia : O2 therapy nasal or head box < 60% , CPAP may be needed ,

Suction , Change position

2- Fluid , electrolytes feeding :- IVF 1st then ryle then oral , Rest 20% ,

Start feeding when RR < 90 by ryle, then when <60 → oral & ↑ gradually

3-Antibiotics

4- Temp. control

5-Nursing

6-Monitoring

7-Discharging when :- ↓ RDS ( RR 50-60) is good , Oral feeding , No jaundice

, infection

Pneumonia

-Organisms :- Bacterial – Viral – Spirochetal – Protozoal –Fungal

-Routes :-

- Trnspalcental – during delivery (GBS . Ecoli ……)- Nosocomial (stph , strepr , GBS . Ecoli ….)

-Risk factors

- PROM – maternal history of (fever & discharge) - MAS- Preterm baby (↓ immunity &mat. antibodies )

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- Following IMV due to septic technique- Diagnosis

- History :- Congenital infection : Critically ill baby at delivery + history of

maternal infection

- Examination:- As sepsis :Poor feeding - RD - Apnea - Cough - Lethargy –

↑or↓ temp , Rales are present ( Crepitation )

- CXR :- Densities – Opacities – Abscess cavity in staph , E.coli , klebsiella

- Lab :- Blood culture or CSF – CRP – CBC ( sepsis work up ) , ABG for

oxygenation

- Management

1.Respiratory support :- Acc. to grade + suctioning

If IMV is needed → it is a respective lung disease so use high pressures

– fio2 – time

2.Antibiotics :as you see e.g :

زيسروماكس –فورتم –اميكين – يوناسين .1 ←for atypical pneumonia

2. فورتم+ فانكو

3. ديفولكان+ فالجيل+ فورتم+ فانكو ( severe cases )

ديفلوكان – فالجيل – ميرونام – فانكو .4

3.Circulatory support if : -hypotension → colloid (10-15 ml/ kg )

-inotropes -Fresh blood → improve also immunity

4.Fluids & Feeding :- Rest 20%

5.Monitoring & Nursing : -Suction -RR –BP – Urine – Saturation

NB :- Congenital pneumonia

1.RD early in life 2.Tachypnea is high 3.Cyanosis

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4. Vent ال على مايتنامش → increase VR

5.CXR → white lung 6.Ausc → ↓ air entry

NB: IF you find opacity & You aren't sure , confirm by C/P (tachypnea + retraction + all One lobe ) AS collapse give same appearance on CXR but wz shift to mediastinum

Imp …. Appearance of pneumonia

1) Lobar → all one lobe ( homogenous ) 2) Bronchial pneumonia → patchy opacities

NB : TTT of collapse >> good physiotherapy & السليم الجنب على الولد نيمNB: follow up of pneumonia by CXR & auscultation

Pulmonary hemorrhage ) P.Hge (

P.Hge is a very serious sign that have very poor prognosis , So the best management for P.Hge is PREVENT its occur .

Def. : Gross bloody secretions are seen in the ETT , It occurs most commonly in acutely in infants on mechanical ventilation between 2-4 days of age .

C\P : The infant has sudden deterioration in respiratory status , suddenly becomes hypoxic , sever retractions , pallor , shock , apnea , bradycardia , cyanosis .

Causes : Hypoxia & trauma are the main causes1- Usually direct trauma to the air way with intubation or vigorous suctioning ,

esp. if the suction catheter is out the ETT .2- Also with coagulopathy ( DIC ) & bleeding from other areas is present .3- Babies with large amount of blood transfusion ( over transfusion ) lead to

→ increase pulmonary capillary pressure , So P.Hge .4- Congenital HF , pulmonary edema accompanies PDA .5- RDs esp. after surfactant injections .

Management : Again PREVENTION is the rule , how :

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- The most common cause is delayed management of hypoxia esp. in premature babies , So acidosis & prematurity lead to Hge .

- The aim is to correct hypoxia & acidosis from early by doing :ABG & see if need to IMV , TTT of acidosis / CBC , CPR , Hct , coagulation profile , PT , PTT

N.B:- CXR → Hge may be focal ( focal , linear , nodular densities ) or

Massive ( complete white out ) & also may be clear .

- Auscultation → tight chest .

Treatment : هـــــام I. Emergency measures :

1- Suction the air way till bleeding subsides 2- ↑ O2 concentration 3- ↑ PEEP to 6-8 cm H2O ( tapenade of capillaries ) 4- ↑ PIP 5- Give epinephrine through ETT (V.C. to pulmonary capillaries )6- IMV الزم 7- بدري , , , من كابرون دايسون هـــام كوناكيون 8- Shock therapy

II. General measures : 1- Support & correct BP ( shock measures , colloids as plasma )2- Correct acidosis 3- Blood & plasma \ 12 hr 4- Avoid excessive volume which lead to ↑ pulmonary edema5- ABG

III. Specific measures : 1- If trauma → surgery 2- If aspirated maternal blood → usually no TTT , self limited 3- For coagulopathy → HDN : vit K, fresh frozen plasma 10ml\kg\12-

24 hr , platelets & monitor coagulation profile .

N.B. HDN ( hemolytic disease of newborn )

Pulmonary hypertension

Old name : Persistence fetal circulation ( but placenta in no more present ) .73

During intrauterine life , shutting of blood occur from Rt to Lt through ductus arteriosus & V.C. of vascular bed ,After birth , pulmonary vasculature start to open & ductus start to close .

Failure of this changes lead to Pulmonary hypertension .

Causes : 1- 1ry → Thick pulmonary capillaries & arterioles with V.C. of ductus

arteriosus in utero , due to maternal ingestions of aspirin or indomethacin or chronic intrauterine hypoxia or idiopathic .

2- 2ry → due to birth asphyxia ( hypoxemia , acidosis ) – RDs ( sever ) – MAS – sever bacterial pneumonia – pneumothorax – PDA – diaphragmatic hernia

Risk factors : 1- Congenital heart disease e.g. PDA .2- MAS , HIE ?? , RDs , GBS infection.3- Maternal Ant PG intake.4- Maternal Lithium TTT .

Diagnosis : جــــدا صعب- History :

1. Term or post term + risk factor .2. Cyanosis in 1st 12 hrs + respiratory distress is minimal → mostly cardiac .3. ↓ Saturation even with ambo , it is ↑ slowly .

- Examination :Cyanosis , tachypnea , RDs sings ( if lung disease ) ,P2 → load, Murmur ( TR)

- CXR : cardiomegaly هـــام + under lying lung disease if 2ry . - ABG : hypoxia + acidosis .- Echo & Doppler هـــام : for any congenital anomalies + shunts .

Management : فايده مافيش حاله ب desataturation و 1- Ambo bag & see what the baby need , observe rate & pressure till ↑

saturation .2- ↓ O2 demand by control temp. & if no IMV give proper sedation & gentle

handle & suction ( ↓ V.C. ) .3- O2 delivery : see the proper route , up to IMV & ↑ FiO2 . 4- Correct acidosis هــام : by Na bicarbonate even you did induced

alkalosis , it help to ↑ oxygenation & ↓ PHTN .5- Restrictions of fluids 30 % .6- Vasodilator فايركتـــا : هـــام نافع ) الــ ambo مش لو . ( خاصة7- No indomethacin if suspect PDA , till you know is it dependant or not .8- Inotropes ( Dobutrex ) → to ↑ C.O.P. + Pulm. V.D. but ↑ BP ( it acts mainly

on blood vessels )

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Pneumothorax

Def. :Collection of air within the close cavity ( pleural ) .

Cause : Rupture in lung tissue that may be spontaneous ,If it sever → may cause shift in heart ( mediastinum area ) .

Risk factors : هـــام 1- IMV األشهــر : esp. in

- preterm(common)- Assisted ventilation with RDs - High PIP , longer time - Slow VR ( rate ) - Baby fight with IMV , So ↓ by sedation or ms. Relaxant or shift to

assisted.2- CPAP also (( اكتر البييب لو خاصه باب السي علي يفرقع عيل ان جدا مشهور

6من 3- Babies who required resuscitation with bag & mask or ETT( يتحسن تالقيه

جدا ازرق يبقي ثم (ثواني4- Staph pneumonia ( abscess & rupture )5- Meconium aspiration syndrome or blood or amniotic fluid aspiration , or

any aspirated material that cause ball-valve effect in airway small branches esp if on IMV .

Complications :1- Hypoxia 2- Acidosis3- IV Hge due to decreases VR to the heart from cerebral veins , hypercarbia

and peripheral arterial constrictions .

Diagnosis : I. History : هـــام

- At risk infant .- Sudden deterioration in the ventilated baby .- Case of cyanosis improved then deterioration with ambo .

N.B. Pneumothorax is an emergency case that need high level of suspicion

II. Examination : األهـــم 75

- Inspection بالعيـــن : 1- Cyanosis ( sudden )2- ↑ R.R. or effort 3- One side become high ( of chest )4- Abd. Distension ( as diaphragmatic is pushed down )5- Apnea

- Palpation باليــــد : 1- Deterioration of general conditions like mottling of the skin , sluggish

peripheral blood flow . 2- Trans illumination test .3- Low blood pressure هــام ( pressure in major veins prevent venous

return ) .- Auscultation بالودن :

1- Breath sounds are louder over one lung ( not easily detected due to radiation ) .

2- Shift of the heart beat ( جدا and you think it is arrest as you don't (هامhear heart beats on apex.

3- Tachycardia (heart failure) then Bradycardia then arrest.

III. CXR : هــــام - AP & Lat. View → jet black appearance , shift of mediastinum .- AP may under estimate the extent of pneumothorax .

IV. ABG : مهـــم و الزم- ↑ PCo2- ↓ PO2 & saturation- ↓ PH - Mixed respiratory & metabolic acidosis

Management : هــــام 1- Small volume , asymptomatic cases :

Observation & monitoring .2- Emergency cases like tension pneumothorax :

Air must be aspirated by needle (butterfly) then >>>>chest canula >>>>.if controlled >>>leave the canula till complete evacuation -if not improved >>>>chest tube is needed.

3- Symptomatic infant who are in IMV may need chest tube insertion.NB: pnemothorax is not an absolute indication for mechanical ventilation.

Needle insertion76

Needle aspiration for pneumothorax

1.Materials used

Butterfly size 23 or 25 Trifle valve 10ml syringe:- under water seal كانه ميه فيه بطبق نستبدلها ممكن Betadine and alchol

2.Sterilization firstbetadine and alcohol

3.Positin supine and someone fix him

4.Attach butterfly to triple valve to syringe

5.Avoid 3rd space and nipple area

6.Determine 2nd space mid clavicular line by determining 3rd first or by sternal angle

(against 2nd space )

7.Insertion is just above 3rd rib to avoid intercostals blood vessels

8.Hold the needle perpendicular to chest and insert

9.As soon as needle enter skin the second person should pull back syringe plugger

(-ve pressure )stop insertion as soon as u get air return

ب الميه سطح تحت االنبوبه خلي طبق هستخدم لو forceps

Transillumination: - See your text

على فرقع الولد لو:- ملحوظة IMV ؟؟ ايه نعملChange setting as follow :- PIP 22 : 26(some say decrease pip but better to judge by

saturation) , Rate 60 : 70 , O2 100 % , Flow 10 , Time 0.38 , PEEP decreased to 3

من اتأكد: ملحوظة endotracheal tube األول

77

Chest tube insertionSee your text

Chest canula

1.Sterilization first

2.Insert canula in 4th or 5th space MAL or AAL(angle 45) till you become below ribs then be horizontal thenpush towards same shoulder under water seal till air

appearance

Do not remove it never till x-ray show cure Important: insertion above lower rib to avoid the (VAN)

After removal sterilize and cover wound

NB:the most sure sign of the corret canula is the oscillation of the fluid level at the end of the line

Neonatal cyanosisDef.

- Arterial saturation less than 90% and pao2 less than 60

- bluish app. Of lips and mucosal membranes

- Cyanosis is emergency and need rapid response

Acrocyanosis:

Hands and feets only are blue and is a normal phenomena after delivery

-Black infant may show lips color that mistakes cyanosis

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Central cyanosis :

-site :lips – tongue –conj. – skin- extremities

Pao2 is low -

Extremities are warm and well perfused-

Peripheral cyanosis :

Site: extremities but tongue-lips-conj. Are pink-

Pao2 is normal-

- Extremities are cold poor refill time

How to manage

First see central or peripheral-

- Causes of central cyanosis(CC):

1. Pulmonary causes:- CC + Signs of RDS present if :

Obstructive : ETT obstruction Or MAS or chonal atresia Restrictive : RDS – pneumonia

2.Cardiac causes:

- CC + No signs of RDS

- Increase with cry

- no improve with O2:-

*It may be lesion with increase pulmonary blood flow TGA-TAPVR-TA

OR

* lesion with decrease pulmonary blood flow TOF- PS

3. Others:79

- CNS (apnea)

- polycythemai(viscosity)

- sepsis(acidosis ,hypoxia , hypotension ,VC ,hypoglycemia >>> cyanosis ,

& hypothermia>>>(lead to acidosis , VC in lung)

What to do ?

1. Give O2 as high aspossible to relieve cyanosis2. Bag and mask even vent.3. Attach oximeter to check SPO24. If apnea tactile stimulation –bag and mask – or ETT.5. If on vent: think first in obstructed and ttt So suck the tube + auscltate chest +see expansion of chest or change tube

NB:- How you know that ETT isn't opened ?

1- cyanosis 2- no air entry 3- no expansion

If suspect pneumothorax confirm then butterfly1. Order: ABG – RBS (hypoglycemia) - CBC(sepsis-polycuthemia) - CRP- CXR

2. Examine:-Vital :temp - blood pressure , Chonal atresia , HT murmur

HSM(sepsis) , Diaphragmatic hernia(scaphoid abd.)

If suspect pulm. Hypertensionvirecta(sildenfil ) If suspect PDA know first PDA dependant or not

N.Bs

1. Sudden cyanosis suspect pneumothorax or obstructed ETT . 2. Cyanosis decreased with crying bilateral chonal atresia

يزرق يسكت ولما يحمر يعيط لما الواد Obligatory nasal breath

3.Cardiac lesion may also present with RDs murmurmay be absent in

TGA cyanosis limited to lower 1/2 of bodyPDA with LT to RT shunt

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4. Cyanosis in upper half of body PHTN -PDA-coarctaion of aorta

5. Patient has Palor + cyanosis >> Pallor may cover on cyanosis in lip and tongue

6. Continous cyanosis Heart & lung disease & Intermittent cyanosis CNS

(apnea)

7. Cyanosis with feeding oesphageal atresia-reflux

ApneaDef : cessation of respire.for 20 sec. or more (some say 15)

Or for shorter time if with bradycardia or cyanosis

Periodic breathing: a regular sequence of resp. pause ?? 10-15 sec. follwed by periods of hyperventilation and occurring at least 3 times /min with no cyanosis or bradycardia ????

Risk factors :

1. Apnea of prematurity (inversely related to gestational age 2. CNS disorders (seizure –IC Hge –hydrocephalus)3. RDs4. Sepsis5. Aspiration 6. Metabolic(acidosis- hypo Na –hypo Ca –hypoglycemia - hypo or hyper thermia

) 7. Upper airway obstruction , GERD8. Hypovolemia –anemia9. NEC –narcotics(maternal) or excess sedation by somonelta or dormicum10.Cold stress

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Apnea of prematurity(needs continuous observation of premature baby)

Causes:

CENTRAL:

1. no signals from CNS to resp. ms (immature brain stem)2. May be induced also by ryle –deep suction – reflux

OBSTRUCTIVE

1. Upper airway obs.+ ineffective resp2. Obstructed by milk or secretion3. Neck hyper extension4. Eye coverMIXED

Same risk factors + or – bradycardia

- The chance of apnea increased as birth weight decrease

- All prematuraties <1800 gm will have at least one apneic spell

- All babies <1000gm will hame apnea

- Usually begin in 2nd 3rd day if onset in second week think other cause

- Also if onset in 1st day pathological

Onset of apnea:

- Within hours after brithmaternal drugs – asphyxia

- Less than 1 week apnea of prematuraty-PDA- IC hge – Post vent

- >1 week ++I.C.T

- 6-10weeksanemaiof prematurity

- At any time sepsis-NEC ….. (risk factors)

Mangement

Babies at risk you should do monitoring of 82

1.HR esp. >100 (set the alarm)

2.resp. monitor(alarm if >20 sec apnea )

3.oximeter (hypoxia)

TTT:

1.Tactile stimulation if no emergency on chest and feet

2.Bag and mask (begin with this step)

3.Then suction of secretion

4.Continue O2 by CPAP or vent(the last step)

5.If brady cardiac massage + PPV + adrenaline

6.Try to know cause by: ABG - RBS – BL.PRESSURE (give inotropes) – Temp –

CBC - CRP- electrolytes- PDA(exam and murmer)

7.give aminophylline as respiratory stimulant (aminophylline is theophylline +

ethlendiamine to increase water solubility >>> increase sensitivity of

respiratory center to increased CO2 tension ) or caffine cetrate which is better

as it avoids aaythmia caused by aminophyline

8. Inotropics :- It is important to continuously observe baby esp. premature

Conclusion

Lines of apnea

1. aminophylline

2.caffine cetrate 5mg /kg/dose(9+1) /24 hours (1cm > 20mg so,after dilution 1cm >2mg )

3.CPAP

4.IMV ( NB > If IMV used > put low setting(why>>> to increase CO2 retention and avoid O2 toxicity )

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CPR

In case of cardiorespiratory arrest : ( no respiration + Bradycardia or no HR )

1. ambu + chest compression 2. Na Bicarb (+ glucose 5 % ) for acidosis up to 3

times3. Ringer lactate (shock therapy) 10-20 cc/kg up

to 2 times4. adrenaline I.V 10 ( المحلل من شرطة )/ kg5. dopamine if on 10 micro 36 شرطة/kg /

dopamine if on 1554 شرطة/kgحمضي وسط في مش قلوي وسط في اال ميشتغلش االدرينالين:- ملحوظة

ملح( محلول سم 9+ ادرينالين سم ا) محلل االدرينالين - If no response , can be repeated every 3 minutes up to 3 times Also you can increase the dose up to 30 شرطة /kg If no response give adrenaline (tube في مركز ) 1 cm

How to do CPR

function of external cardiac massage:

- Compress heart against spine

- ++ intrathoacic pressure

- Circulate blood to vital organs of body

- 2 people are required one to compress and the other to ventilate

Technique 2(thumb or 2 finger ) (( Thumb tech. ))

2 thumb to depress sternum while hands encircle the chest and 2 fingers support spine (baby on firm thing) , Thumb flexed at 1st joint and pressure applied

vertically to compress heart between sternum and spine , Thumbs are side by side

84

or in small baby make them one over the other , Neck slightly extended+ baby one firm matter , Site: lower 1/3 of stetrnum between xiphoid and line between two

nipples avoid direct preesure on xiphoid

Pressure : same Rate . depth . loction

Dept: 1/3 of AP of chest

Rate : 3 compress:1 vent. Or 4:1 and 30 breath and 90 compress /min

When heart rate exceeds 100 >>> stop compress and do breathing

ال توقف انك, رجع القلب ان معنى مش بالك خد:- ملحوظة CPR يكون ممكن ده ألن يــ يرجع دقائق وبعد, االدرينالين تأثير Arrest ال تكمل انك فيستحسن, تانى

Compression ال حاالت بعد وفى, مناسبة لفترة Severe

ادرينالين تحتاج ممكن Infusion

-: ملحوظة

Adrenaline infusion

1 بمعدل اليوم مدار على وتمشيها سم 24 % ..... 5 جلوكوز سم 23+ مركز سم 1 - ساعة/ سم

االدرينالين على معتمد لسه لكن رجع الطفل لو ؟ نديه امتى -

Vomiting

Vomiting in well doing baby:

1.over feeding / faulty feeding2.swallowed aminiotic fluid or blood(maternal)3.GERD4.CHPS (pyloric stenosis)

85

vomiting in sick baby

1.intestinal obstruction2.NEC (inborn error of metabolism )3.sepsis(Pneumonia - UTI – gastroenteritis –meningitis)4.increased I.C.T

Investigations :- sepsis work up – x-ray erect&supine – barium cranial US – electrolytes – Bicarb – metabolic screen

NB:- You should compensate the loss + if severe >> NPO

Diaphragmatic hernia Diagnosis:

- mainly prenatal

- severe RDs in first few hours

- scaphoid abdomen

- inflated chest

- unequal breath sound +intestinal sounds

- x-ray shows gas of stomach and intestine in chest + shift of heart + small lung

Treatment:

Surgery (emergency) >> ( Pre operative) : - Good oxygenation

- intubation

- Metabolic support

- NG( Ryle)

- Arterial catheter for ABG

NB: Do gastric decompression by Ryle /// Not inflate by ambu and mask as by this action , You will inflate stomach & intestine &compress chest more and more

86

More details about diaphragmatic hernia

- it is apredisposing factor for pulmonary HTN & HF

- C/P ( white lung in CXR )

* worsing with bag and mask

*asymmetrical breath sounds following ETT depending on location of CDH

* if suspected do CXR with injection of air in ryle

* auscultation reveals diminished breath sounds on the affected side & some times intestinal sounds on affected side

تسمع---- البطن فى----- كده غريبة االنبوبة ان وتحس Crepitations

* shift of heart impulse to right side

وغالبا جدا مهمة عالمة ودى Misdiagnosed as Dextrocardia

Infant of diabetic motherIDM

هم 3أهم األول فيهم نفكر حاجات :1- Hypoglycemia : mainly in macrosomia

= RBS ˂ 40 mg\dl , Onset 1 – 2 hr of age , Cause : neonatal hyperinsulinemia – hypoglycemiaManagement : هـــــام C\P : lethargy , poor feeding , apnea , jitterness

Measure blood glucose ( RBS ) at :- Once \ hr in the 1st 4 hrs - Once \ 6 hr till end of the 1st day - Once \ 12 hr till end of the 2nd day

So : at 1,2,3,4,6,12,24,36,48 , If hypoglycemia : manage √√

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2- Respiratory distress : Cause : delayed lung maturity caused by hyperinsulinemia that blocks cortisol induction of the lung maturityOthers : cardiac & pulmonary anomalies , polycythemia , pneumothorax , pneumonia , C.S. delivery( TTN ) , diaphragmatic hernia.Management : CXR , ABG , ECG , ECHO , CBC , Blood cultures If RD : manage √√

3- Hypocalcaemia : in 50 % of cases Cause : controverse : delayed in parathromone or Vit D antagonize by cortisol , asphyxia , prematurity Occure in the 1st 24 – 27 hr , Ca ˂ 7 mg \dl ( total )Invest. : total serum Ca / ionized CaManagement : prophylactic : Ca from 1st day , curative : C/P & TTT

ال لآلخر 3بعد األول من الواد نمسك نبدأ دول :1- Resuscitation2- Search for any congenital anomalies3- Vital data specially RR , HR , BP , Perfusion4- Trauma : brachial plexus , fracture clavicle or limbs5- Small for G.A. : suspect mother with renal or cardiac diseases , prematurity 6- Reflexes7- Invest. for CBC , HB , HCT , CXR , Ca , Bilirubin , ABG 8- Feeding : حســـب علـــى

Other problems : 1- Polycythemia : partial exchange transfusion ??2- Jaundice : هـــام

Cause : - indirect : polycythemia → more distruction , prematurity - direct : من بالك سبب $ inspisated bile → خد Treatment : as ) أشهرjaundice , early obstruction , early lab. , early phototherapy )

3- Congenital anomalies : see ↑ with bad contol as cardiac , CNS & Vertebra , skeletal , renal

4- Macrosomia ˃ 4 kg or 90 %Cause : insulin & glucose C\P : hypoglycemia & trauma

5- Myocardial dysfunction : Cause : ventricular septal hypertrophy ( idiopathic ) C\P : CHF , poor C.O.P. , CardiomegalyCXR : cardiomegalyEcho is diagnostic

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Resolve in 4 months & symptoms ↓ at 2 weeks Inotropics contraindicated unless myocardial dysfunction by Echo N.B. HOCM TTT : Inderal ,NOT lazix , capoten, lanoxine

6- Renal vein thrombosis : C\P : hematuria , flank mass , hypertension , embolic phenomena + + دم ضغط ورمInv. : U\S , TTT : conserve

7- Poor feeding √√

8- Small left colon syndrome : Generalized abd. Distension due to inability to pass meconiumTTT : enema or glycerin supp. + ↓feed + ↑ IV fluid محاليل

9- Hepatosplenomegaly

Post maturity : - Problems : 1- RD 2- Hypoglycemia3- Hypocalcemia4- Polycythemia5- Birth trauma , very large size baby

Jitteriness DD :1- Hypocalcaemia : exclude 1st ( double ca )2- Hypoglycemia : exclude 2nd

3- Renal impairment : ask renal inv.4- Hyperbilirubinemia : هــام esp. direct type

Jitteriness , ال مع تقف اليد ملحوظة :- Jitteriness وال Convulsions نمسكبين للتفريق

Prematurity هــــــام( الوالدة حديثي األطفــــال (

- Def. & class :1) Late preterm ˃ 35 w → mild problems need → monitoring

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2) Early preterm ˂ 35 w → have problems If ˂ 32 w → need intubation

- Problems :1- Respiratory distress :

ABG اطلب بــ CPAP ثم معـــاه عيل 1500˂ ابدأ أيSee the grades √√Inv. : CXR , ABG , CRP , CBC TTT : oxygen , CPAP , IMV , surfactant

2- Apnea : Esp. in ˂ 35 w , esp. from 2nd day , TTT : Tactile stimulation , bag & mask , drug like aminophyline , CPAP , IMV

3- Blood glucose : Hypoglycemia : due to ↓ stores & lead to brain damage, So RBS is a role Hyperglycemia : √√

4- Hypothermia : Measure temp. regularlyTTT : الكشاف و الحضــانة

5- Feeding & fluid : Hypocalcaemia ( Ca add from 1st day ) : manage & TTT There is in-coordination between suckling , swallowing &

breathing in ˂ 34w SO start with IV fluid & Rest. If RD → glucose 10 % 2 days at least ,Then ryle D 5 % then milk → baby lac PT & monitor residual & distension to avoid NEC + regular weighting

6- Hypotension : Cause : blood loss , infection , hypoxia , acidosisCheck BP regularlyTTT : of the cause , use for Inotropics drug as dopamine & dobutrex , give blood & albumin .

7- Anemia : Inv. : CBC , HCT , Hb TTT : √√N.B. IF there is frequent ↓ Hb deterioration in general condition ē ↑ apnea ē seizures → search for IChge

8- Hyperbilirubinemia : Very common esp. those on IVF and delayed feeding & liable for toxicity at lower levels Inv. : TSB , DSB & photo in indirect type & exchanges in sever cases & add IVF 10% - 20%

9- Sepsis and low immunity : Triple بــ معــاه نبدأ ممكنCommon esp. if PROM

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Inv. ( routine ) : CBC , CRP Start AB if suspected C\P : not doing well, poor suckling , feeding intolerance, abdominal distension , apnea , lethargy , irritability , seizures حاجات 3أهم

10- CNS problems : CNS infection , IChge C\P : seizures ……………Prophylactic: ↓ maneuvers, gentle care , avoid sudden change in fluid , IMV, ..Inv. : lumbar puncture & U\SManage seizures √√

11- PDA : Due to hypoxia → murmer & HFConfirm by EchoTTT : good oxygenation , diuretics , ↓ fluids ,Indomethacin , surgery

12- GIT : NEC so take care in feeding

13- Ophthalmology.:ROP esp in < 32 w , or < 1500 gm

14- Good nursing 15- When to discharge :

o no RD or apneao good feedingo temperature stable o gain of weight, Esp. > 1700 gm

ال فى الشيت غالبا مجمال Preterm

كاالتى-CPAP or Vent

- For hypothermiaكشاف

-Minimal handling

Glucose 10% 2 days - محاليل

-Ca from 1st day

-Unacin, Amikin, Fortum

سومونليتا و دورميكيم -

-Konakion91

-Dopamin, Dobutamine

-Plasma for anemia

-Moitor Bl.Pr >>shock

Urination - نتابع

IUGR <2500 gm

Problems:

1-RD & asphyxia

2-Hypoglycemia

3- Congenital Malformation

4- Sepsis

5- Hypocalcemia

6-Hypothermia

7- Polycythemia >> increase fluids

8-PPHN (Persistant pulmonary HTN of Newborn)

Due to chronic intrauterine hypoxia >> thickening of smooth ms of small pulmonary arteries.

So don't forget,,

1-O2

2-Aminophylline>>for apnea

3- Ca Dobule

4- Zantac for stress ulcer

5-Abs

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Jaundice )الصفراء )هام جدا

1-Bilirubin::

-Formed from hemoglobin due to red cell breakdown

-2 forms> Direct(conjugated) ,Indirect(un conjugated)

-Bounded to albumin (Indirect) conjugated in liver (direct) & excreted in stool

-measured by mg/dl or M mol/l & (mg/dl X 17.1= m mol/l)

-indirect is orange yellow & direct is greenish yellow.

-in dark babies >>press your finger on skin & observe

2- Why bilirubin is dangerous??

-can stain the brain if inexcess amount or if no sufficient albumin so free bilirubin forms pass BBB . Also if baby is severly distressed(acidosis, hypoxia, hypoglycemia,

hypothermia, PT) BBB disturbed &even bounded bilirubin can pass.

3- Factors increase the risk of hyperbilirubinemia:

1) Prematurity:due to immature liver , low serum albumin , stress so liable to

Kerinctrous at lower levels.

2) Hemolysis: due to Rh or ABO incompitability or drugs or sepsis

3) Free fatty acids: if malnourished, cold, hypoglycemia.

4) Drugs: cefriaxone, gentamicin, Lasix, digoxin, aminophylline, indomethacine,

valum, salfa, salicylate

4- Causes of hyperbilirubinemia::

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a-Physiological jaundice

b-hemolytic states: Indirect+ anemia

-Isoimmune; Rh , ABO

-Congenital hemolytic anemia: G6PD, Thalassemia, spherocytosis

-Hematoma, excess brusies, polycythemia

c-Mixed hemolytic &hepatotoxic states: increase direct & indirect bilirubin.

As bacterial infection, TORCH, Drugs, vit K deficiency

d-Hepatocellular damage: Both direct(>20% of Total) +indirect , like biliary

atresia , galactosemia, hepatitis

e-Uncertain mechanism: breast milk jaundice, racial

5-DD of neonatal jaundice::

Physical Exam. Lab Cause TTT

1-jaundice + normal appearance (+-) PT

-ve combs, normal HCT, retics ,film

-immature liver

-decrease conjugation

Good hydration ( + -)photo

2- J + normal app. + pallor + tachypnea +

CHF

+ve combs +low HCT + high retics + ab.film

-hemolysis:Rh or ABO

-antibodies& anemia for longer

3-J + HSM + Leathergy + hypothermia + poor

feeding

-increase direct + indirect , -ve combs, low HCT, +ve sepsis

work up

-sepsis -Abs

-no photo if high direct

4-J + Plerthoric + SGA or one of twins

-ve combs, high HCT , normal retics

Polycythemia -as before

-partial exchange

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5-J + CHD + HSM + Catarct + microcephaly

-high direct, +ve culture or AB for

torch

-congenital intrauterine

infection

Medical ttt of cause

6- J + Abd distension + vomiting + no stool

-increase indirect, others > normal

GIT obstruction -hydration + NPO + NG suction + X-ray

7- J+ multiple brusies + difficult labor + head

swelling

-ve combs, others :normal

Cephalo-hematoma

As before

8- J + long time + breast fed + all normal

All normal Breast milk jaundice

Follow up, stop breast fed 2 days,

artificial milk

6- Types in details::

1-Physiological jaundice:

-Very common 2/3 -rise >12 mg/dl up to 15 -In preterm: peak 10mg/dl

-Doesn't appear in 1st 24 h -In PT appear later but stay longer

-Increase by less than 0.5mg/dl/h

-N.B:: No signs of ill health: Vomiting, lethargy, poor feeding, excessive wt loss,

apnea , tachypnea, temperature instability

Physiological

PTFT

Appearance 3 , 41414

Appearance 2 , 3Up to 12

Duration 7 – 10

2- Prolonged jaundice :

Def. : apparent jaundice for 10 days after birth in full term baby & for 2 weeks in preterm baby .

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Cause : breast milk jaundice is the commonest & non specific hepatitis in VLBW

Other causes : sepsis ( UTI ) – hypothyroidism – inspissated bile syndrome ( very high unconjugated bilirubin followed by conj. ) – delayed passage of stool – pyloric stenosis – obstructed jaundice syndrome .

3- Breast milk jaundice :

Usually at day 4 , bilirubin fall but here it continues to rise up to 20 mg\dl at 10 – 14 day of age .

If breast feeding is continued , the level stay elevated then fall slowly . If breast feeding stopped , bilirubin level fall rapidly within 48 hr & when

breast feeding resumed the level rises again but not the previous high level . يومين نوقف

Recurrence is common in next pregnancy 70 % Can lead to kernicterus . Unknown cause but some say pregnandiol in milk suppress conjugated enzyme

4- Breast feeding jaundice :

Infants who are breast feed have higher bilirubin level compared to formula feed infants .

Cause : ↓ intake of milk → ↑ enterohepatic circulation → Cholostrum → constipation → ↑ enterohepatic circulation

5- Inspissated bile syndrome :

Persistence icterus in association. With significance elevation in direct & indirect bilirubin in infant with hemolytic disease

cause unknown but jaundice ↓ spontaneously in weeks or months .

6- Jaundice with G6PD ↓

7- ABO incompatibility :

It is an iso immune hemolysis occur with blood type A or B infants born to type O mother , transplacental transport of maternal iso antibodies ( of the IgG type ) , results in an immune reaction with the A or B antigen of fetal erythrocytes , which produces ch.ch. micro spherocytes .

Risk factors :A1 ( type A has A1 & A2 ) – antepartum– intestinal parasitic infections – 3rd trimester immunization with tetanus toxiod or pneumococcal vaccine .

Jaundice appear in 1st 24 hr with rapid increase of the indirect element , anemia is not sever due to effective compensation by reticulocytosis .

Diagnosis : blood group of the mother & baby , Rh retics, direct Comb’s test , blood smear for spherocytes , total serum bilirubin .

Phototherapy : is the usual TTT ( if ↑ → exchange transfusion )96

8- Rh incompatibility :

In Rh –ve mother ( sensitized to Rh +ve ) & Rh +ve baby Prophylaxis by ( Rho GAM ) Risk factors : not in the 1st pregnancy unless previously sensitized ,

fetomaternal hge , male > female , C.S. , trauma . If accompanied with ABO incompatibility , the risk of Rh incompatibility will

decrease due to rapid immune clearance of the fetal blood cells after entry to mother .

C\P : jaundice + anemia in 1st 24 hr + or – HSM Inv. : blood group & Rh of infant & mother , retics , direct Comb’s test , TSB ,

DSB , RBS . TTT √√

9- Emergency management of sever erythroplastosis ( hydrops fetalis ) :

Most of infant are delivered by C.S. Resuscitation may need intubation , aspiration of pleural or peritoneal effusion. UMC ( umbilical vein cath. ) – check Hb & bilirubin – Comb’s test - transfer

to NICU . Mechanical ventilation if RD , HF , pulmonary hypoplasia Early exchange transfusion . May need digitalis , diuretics . Clotting screen after 1 hr from combination of ex. transfusion .

10- Kernicterus ( apnea & convulsion ) :

Def. : it is a pathological diagnosis describing by yellow staining of the basal ganglia due to high level of free bilirubin or due to increase permeability of the brain , esp. seen in preterm babies .

Cells of basal ganglia in the midbrain are metabolic active & receive the largest blood flow .

It is risk ↑ with immaturity , rapidly raising bilirubin , low albumin , hypoxia , acidosis , sepsis , hypoglycemia .

C\P : initially , infant has non sp. Signs of like poor suck , lethargy of hypotonia + high jaundice & within hours , it progresses to fever , hypertonia of extensor ms. Groups leading to opisthotones (trunk & neck arching) ,also convulsions may be +ve

If left un treated : fetal or sever brain damage can occur Preterm infant may develop apnea with ↑ tone . Immediate exchange transfusion better proceeded by albumin transfusion ,

should be done .

11- Indirect hyperbilirubinemia ( cong. ) :

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Def. : if direct bilirubin > 20 % of total or > 2 mg\dl , A persistence or ↑ elevated direct bilirubin is always pathological & must be evaluated & a value > 5 mg\dl is consider sever case .

Causes : Idiopathic neonatal hepatitis , the most common (by exclusion).Biliry atresia : 2nd common cause , need surgery otherwise LCFTPN ( unknown mechanism ) if > 2 w esp. in preterm infant .Sepsis or UTI هـــام Intrauterine infections ( TORCH )Inspissated bile syndrome هــــام

Choledocal cyst , antitrypsin ↓

Galactosemia Inv. : liver functions – CBC – urine & blood culture – reties – Coomb’s test –

TORCH screen – U\S for liver & biliary tract – liver biopsy – radionuclide scan .

Clinical application إيه معـاها الــ Jaundice نعمــل حالـــــة

a) History : - Prenatal , natal , postnatal history - feeding pattern – family history of hemolysis - previous jaundiced baby .- Rh status - Time of start هـام إمتى يالحظوها بدأوا

b) Examination : - Color : indirect أصفر \ direct اللون أخضر أوال هــام ← - Distribution : هــام

6الرأس ← 9الصدر ←

12البطن ← الرجلين ← و اليدين من العلوي 15الجزءمن ← أكثر السفلي 15الجزء

- Look of signs of infections- Look for area of accumulated blood as cephalohematoma or bruises . - Liver & spleen size ( if ↑ → hemolysis ) - Pallor هـــام , suckling هــام , feeding ability

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c) Investigation هــــام : Start ē TSB , DSB , reties - Severity الــ و النوع تحليل bilirubin هتعرف من أوال

Indirect في األشهر إنهــا hemolysis وده من reties هتعرف ونطلب لـــو reties : عالية و

- ABO groups for infant & mother الطفل و لألم الدم فصيلة( usual In the 1st 3 days ,esp. in the 1st day أول في من 3غالبا خاصة و أيام

يوم ( أول- ABO incompatibility ← B or A الطفل األم O و لو

عنه اسأل في Rh و فكر أل لو- Direct طلع bilirubin تحليل لو

؟ ينطلب اللى ايه شوف غالبا inspissated bile syndrome وساعاتها يبقىCBC → for anemia CRP → for infections esp. UTI

N.B.

* Jaundice > 14 days must be investigated At least by TSB - DSB – Hct –

thyroid function – urine culture .

* It is not physiologic if appear in the 1st 24 hr or ↑ by 0.5 mg\dl\hr or > 2 in 4 hr or

evidence of hemolysis – abd. examination – or direct > 20 % or

persistence > 3 weeks .

* Infant with breast feeding jaundice are liable for hemorrhagic diseases , So be

sure that baby take prophylactic dose of Vit K

* Skin color is not guide for hyperbilirubinemia in infant under photo.

d) Treatment : لو ( العيل على ≥ ) ( 12ندخل نخرجه ≤ )7و

Triple رقم لو بــ 20حتى ابــــــدأ 1- Phototherapy √√ like tables 2- Exchange transfusion :

( Triple على األول حطه محتاجه ( لو( Photo + تحويل كل + ورق التحليل ساعات 6محور )

3- Good hydration √√ , effective feeding , IVFكل ساعات 3 - 2الرضاعة

4- In breast milk jaundice , stop for 2 days & give artificial 5- Kernicterus & convulsion → give anti convulsion

99

6- Sepsis → give Antibiotics ( exchange ماينفعشي 19أو 18لو و → do triple + good feeding \ 2 hr )

e) Management of hyperbilirubinemia in healthy term baby :

Day Age (hr) Photo ( TSB\mg\dl ) Exchange transfusion

1st Up to 24 10 - 12 20

2nd 25-48 12 – 15 20 – 25

3rd 49-72 15 – 18 25 – 30

4th >73 18 – 20 25 – 30

f) Management of hyperbilirubinemia in sick term baby :

Age (hr) Photo ( TSB\mg\dl ) Exchange transfusion

Up to 24 7 - 10 18

25-48 10 – 12 20

49-72 12 – 15 20

>73 12 – 15 20

g) Management of hyperbilirubinemia in healthy & sick preterm <37w baby :

Healthy baby Sick baby

Weight photo exchange photo Exchange

Up to 1 kg 5 – 7 10 4 – 6 8 - 10

1 : 1.5 7 - 10 10 – 15 6 - 8 10 – 12

1.5 : 2 10 17 8 – 10 15

> 2 kg 10 – 12 18 10 17

h) TTT of direct jaundice هــــام :1- Over hydration + كويسه رضاعة2- 1cm \ kg \ day → (Cholaguoge) أورسيجول 3- , % bile acid sequestration )→ 1sach. \ 10cm glucose 5 كولسيتران(

100

2cm \ kg \ dose \ 12hr

ساعات 3 أو 2 كل ترضع األم على نبه الـــخروج بعد و:- ملحوظة

Phototherapy

Used for indirect hyperbilirubinemia not the direct .

- lamps have wavelength between 425 – 475 nm .

- there is no benefit from ordinary fluorescent lamps . - light produced well convert indirect to non harmful substance .

- double photo is used in high level .

- contraindicated in porphyria .

Types of phototherapy :

1- Conventional

2- Prophylactic : in VLBW , cephalohematoma , polycythemia .

3- Intensive photo :

- Put lamps within 15-20 cm of infant

- ↑ number of lamps

- May use phototherapy blankets under the infant

Procedure ( single or double ) :

- Distance : 35-50 cm , and if baby inside incubator → put 5-8 cm distance between lamps & incubator .

- Baby undressed except napkin area & eyes .

- Turn baby every 2 hr to ↑ surface area .

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- Temp. follow up regularly ( heat , loose stool , dehydration ) .

- Clean baby only by water , no oil or creams .

- Weight baby daily .

- 10-20 % add to fluids .

- Don’t judge by skin color any more .

- Check bilirubin every 12-24 hr up to 48 hr .

- Remove photo when bilirubin became < 7-10 mg\dl .

- Then follow up bilirubin 24 hr after TTT for rebound hyperbilirubinemia .

- Good feeding .

Bli-bild device

Advan :- more exposure ( increase surface area )

Disadvantage :- hypothermia >> poor suckling

Problems :

1- ↓ transit time → diarrhea .

2- Dehydration .

3- Hyperthermia .

4- Rash → examine regularly .

5- Eye problems if exposed → so turn off

العيل عين عن وقعت النظارة لو اطفيه بمعنى 6- Bronze baby syndrome if used in direct bilirubin .7- Genital problems if exposed .

8- Anxiety to parents .

Other N.Bs in Jaundice

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Indirect bilirubin : fat soluble , carried on albumin , not excreted by kidney but pass BBB & cause kernicterus .

Direct bilirubin : water soluble , excreted in bile & kidney , not pass BBB but its underlying cause is dangerous .

Indirect hyperbilirubinemia may lead to direct one by inspissated bile syndrome .

Rate of rise in pathological jaundice > 5 mg \ dl \ day If childe on curve need exchange , we may try intensive photo

( 45cm → 25cm ) . Rate of ↓ 0.2 mg \ dl \ hr , So after 4 hr → 0.8 . Breast feeding jaundice :

أول في و 3طفل صدرها في لبن مفيش هتقولك األم و كويس بيرضع مش أيامو ساعتين كل يرضع إنه المفروض عالجه ، كراويه و ينسون له بتدي و بيكفي مش

صناعي لبن تجيب فيش ما لو Breast milk jaundice :

من أول الصفرا جتلو و كويس يرضع الرضاعة 10-7دهب توقف إنها عالجه ، أيامتاني يرضع بعدين و ، فوتو يحتاج وممكن صناعي لبن ياخد و كده يومين لمدة

هترجع مش و عادي Phenobarbitone = sominalette → 5 mg \ kg \ dose

بينيم ألنه به ينصح ال بس الجويندز حاالت في يستخدم ممكن Mechanism → enzyme inducer

بتخرج اللي الحاالت المحضن متابعة تسأل من الزم ، اتصلت االم لو التليفون في : عن1- Feeding ( frequency ) + كراويه و ب ينسون امساك النهم يزودوا يعملوا وبالتالي

بتدي الصفرا لو2- Abd. Distension3- Suckling power الرضعة بداية في الشفط قوة4- Hypoactivity >> sleep with no cry

تاني دي التحاليل منها تطلب : و- TSB , DSB - CBC

Neonatal convulsions ) seizures (

It is critical to recognize neonatal seizures & known their etiology & TTT them urgently .

Complications :103

1- The cause is usually serious 2- ↑ O2 consumption , So ↑ hypoxia & brain injury .3- Interfere with supportive measurement as ventilation & elimination .

Causes :1- HIE √√ : the single most common cause ( see later )2- IChge 3- CNS infection : see later 4- Metabolic as :

- Hypoglycemia √- Hypocalcaemia √- Hypothermia √- Vit B6 ↓ ( cortigen B6 ) √ هـــــام

Exclusion بـالــ يتشخصConvulsion resistance to TTT & TTT by 0.5 cm IM cortigen B6

5- Kernicterus 6- Polycythemia 7- Developmental8- Drug withdrawal 9- Familial 10- Others like : Fifth day Fits , hydrocephalus

N.B.

it is important to diff. between jitteriness & convulsion ( for jitteriness see IDM ):-

الــ تمسك إنك طريق عن بينهم تفرق Limb .... تكون الحركة وقفت لو Jitteriness

تكون وقفت مش لو ← Convulsion

Management :

104

Emergent measures باختصار

1- check ETT + increase FIO2 + glucose measurement +give ca

1- TTT of cause √√So inv. ( Ca total ionized , glucose , bilirubin , CRP )

2- Supportive measurement ( ABC ) : O2 , suction , position(see later)3- Anticonvulsant drug أديها إمتى

Significant كانت لو إنها convulsion و اتأكدت لو↓ saturation عامله ← Significant انها إزاي تعرف

Drugs : األدويــــــــــــــة

الكتب طريقه

1- Phenobarbitol ( PB ) = سومنوليتا - Is the 1st line drug & it is sedative - It is give loading dose of 15 mg \ kg \dose over 10 min.

+ careful monitoring of respiration .- If initial dose is effective wait for 0.5 hr , the additional dose of 5 mg \kg \ dose can be given every 5 min. till seizures ↓ or a total dose of 40 mg \ kg is reached .- Then maintenance 5 mg\kg\day is given &started 12 hr after loading dose

2-phenytoin = epanutin

- If convulsion persist or total dose of Phenobarbitol ( 40 mg\kg ) is reached .

- Give loading dose 15 mg \ kg \ dose & monitor cardiac rate & rhythm ( cause cardiac dysfunction ) .

- Maintenance : 5 – 8 mg \ kg \ day in 2 doses - Maintenance dose كل كالهما يعطي آخر بالتبادل 6رأي ساعات - Withdrawal هـــــــــــــــــــــــام :

If 5 days free without convulsion Very slowly withdrawal شديد ببطء يكون السحب After 4 months do EEG , complete neurological examination &

CT .

N.B.

105

( االغلب من تستخدم التى وهى) باختصار

1- give somonileta 15 mg/kg as (L) & wait 0.5 hour if no Response give another loading & wait 0.5 hour

2- If no R give epanutin then

1st of all do ABC for the infant :- A : airway by suction & change tube - B : O2 ( give adequate O2 ) + ↑ Fio2 - C : cannula + shock TTT + dopamine & dobutrex dose 5

Search & TTT the cause , e.g. :- Hypoglycemia if asymptomatic give 2 ml \ kg

If symptomatic as convulsion give 4 ml \ kg - Hypotension : measure BP & TTT- Hypocalcaemia : double Ca dose- Vit B6 ↓: 0.5 cm IM cortigen B6

Conv. Resist for TTT ← إنــــها تعرف و

CNS infection ) Meningitis (

Diagnosis : The organism may be streptococci ( GBS ) – E.coli – H.influanza .C\P :1- Bulging fontanel ( anterior )2- Arching back3- Convulsions 4- Hypo or hyperthermia5- Neck rigidity

Investigations : CBC , CRPLP ( lumbar puncher ) for CSF

Treatment : 1- Drugs لــ مائــي → أرجع بنسلين

الجرعة 100.000مش 200.000 : 300.000و2- فانكـــو + 3- May + سيفتراكزون4- May + لوفــير → antiviral ( tab = 400 mg )

0.5 tab \ 5cm glucose 5 % \ 8 hr = التخفيــــف Dose = 10 mg \ kg \ dose

5- ميروتام + فانكو6- TTT of convulsions → anticonvulsant drug √√ 7- Supportive measurement

106

Umbilical venous catheter

A- Indications :

1_ Urgent administration of resuscitation drugs or adrenline .

2 – Hypertonic solution 12.5 .

3 – Giving blood and blood products .

4 – Measure CVP .

5 – Exchange transfusion .

6 – In no cannula can be done

B- Contraindications :

1 – Omphalitis

2 – Omphalocele

3 – NEC

4 – Peritoritis

C- Tools :

1 – dressing - betadine – alcohol

2 – blade – forceps – syringe – silk suture 3/ 0

3 –Flush solution ( Normal.saline + 1 unit . heparin )

4 – unbilical catheter

a - 3.5 for ELBW b - 5 for < 3.5 kg c - 8 for > 3.5 kg

107

D- Steralization (Clean , Tie , Cut )

1 – Betadine ( 3 times )

2 – alcohol ( one time )

E-

ال طرى cord (المثالى ال على حاجة نربط االول base ال عشان (blood

F-

االول القسطرة وجرب ملح محلول وامالها سرنجة وصلG- cut the cord and remove clots and leave 1- 1.5 cm

H- identify the vein (one vein has wide small lumen and 2 thick arteries)

I- measure distance >> from umbilicus to xiphoid + 1cm of cord √√√√

>> or from umbilicus to shoulder and take 2/3 only

>> or (Wt X 3 ) + 9 / 2

NB:- Don't touch infant body by catheter

J- insert UVC …… No resistance is must >> if present >> aspirate clots

K- confirm >>

القسطرة هتالقى السرة فوق بايديك حس - superficial

هتالقى بالسرنجه اسحب - continous flow and not pulsating

ال فى انها معناه ده - IVC ال وليس liver sinusoids هتالقى كنت واال interrupted flow

اطلب و x_ray ( جدا هام محاليل فيها تمشى ما قبل (

L- suture by silk >> by purse string suture

M- fix catheter

108

N-nursing care & frequent cleaning of catheter

O-removal (7-14) days without complications / or reached 15cm

Complications

A. Air embolism

B. thrombosis

C. malposition>>>> If inserted in

1. right atrium or SVC >>> pericardial effusion 2. arrhythmia

3. hydrothorax if inserted in pulmonary veins

4. may leads to distention if inserted in liver 5. leakage

D. hepatic necrosis ( not give drugs contain Ca )

E. sepsis >>>depend on >> 1.maturity 2.technique 3.days

4.malcare 5.heparin

تكون الخياطة:- ملحوظة purse string ال حول لفها ثم cord, ال تاخد ممكن artery ثم كمان ال لف ثم القسطرة حول لف cord تانى

Problems >> resistance

1. فيه يكون احس اسحب clots

2. تانى وادخل شويه بالقسطرة ارجعsaline احقن.3

4. داخل انت ما طول القسطرة لف5. اليمين ناحيه من القسطرة زق

فكريل أو احسن silk ) خيط .6 Weak )

فيه لو:- ملحوظة resistance الجلد تخرم ممكن عشان جامد متعافرش

NB :- x-ray findings109

1. if to right >> hepatic

2.above >>>upper border of liver

3.run in middle of vertebral column till T9 at least

Endotracheal intubation )ETI(

Sizes

1. < 1 kg >>>>2.5 (if <28 wk)

2. (1-2)kg >>>>3 (from 28 wk to 34 wk)

3. (2-3)kg >>>>3.5 (from 34 wk to 38 wk)

4. > 3 kg >>>>4 (>38 wk)

N.B

1. problems with use of smaller tubes than need leads to leakage of air

2.problems with use of larger tubes than need leads to laryngeal odema and injury

Indications

1.IMV

2.tracheal suction

3.In CPR

Procedure

1.position : slight extension

2.use laryngoscope (check light)

110

3.when you insert , you will find darkness , so pull it backwards till you find epiglottis

4.push it forward till you find vocal cords (moving)

5.insert the tube but avoid forced insertion

Fixation

1.if oral >>> 6 cm +wt

2.if nasal (not used) >>> 7 cm +wt

N.B

You should use ambo first to improve saturation and also for suction

Confirmation of position

1.you can see water vapour with breath

2.auscultation: by ambo better on rt axilla and left axilla and both sides of chest and if air entry

is heard equally or not (you may find right side more , so pull the tube above and hear again)

3.symmetrical chest inflation

4.no gastric distention with breath

Complication

1.obstructed ETT by secretions or kinking:will find cyanosis , desaturation and by

auscultation , you will find diminished Sounds and decreased chest inflation ,so change

the tube or make suction

2.infection

111

3.injury to vocal cords and esophageus

4.pneumothorax if there is increase in PV or in case of right side intubation

5.bradycardia due to hypoxia or vagal stimulation

6.hypoxia

Hyperglycemia

-Definition:- blood glucose >150 mg/dl (>8mmol/L )

-Complication:

1-if blood glucose >a80 mg / dl >>>osmotic diuresis , dehydration ,acidosis

2-if serum osmolality >300mosm /L>>> cerebral He

N.B:

-serum osmolality=2 (Na by mmol/L+K by m mol/L)+urea by m mol L+glucose by mmol/L

-Urea (mg/ dl)/ 6 =m mol/L

-glucose(mg/dl) / 18 ==m mol /L

- Causes:

1-iatrogenic ( TPN )

2-prematurity & ELBW ( due to decreased glucose utilization )112

3-sepsis: stress – asphyxia –intracranial Hge

4-drug as steroid , theophyllin

5-neonatal DM

6-ingestion of hyperosmolar formula

- Diagnosis:

*monitoring for high risk *N.B: don't take sample from vein where i.v line is present with glucose infusion

- TTT:

A-Prevention :- ELBW < 1gh >>> give D 5 or 7.5 not 10 % in first few days

B- Curative : ( don't stop solutions , but You can decrease rate )

1-reduce the concentration of glucose >> 10 - 5 - 7.5 ( that if in the first few days )

2 الخلطات - :

- if no response & > 180 mg/dl >>>

give glucose ( 5-7.5-10) : saline or ringer lactate

4 : 1

+ 1cm Kcl every 100 cm or 1 cc/kg/day

+ monitoring every 30 min

- if no response >>>

1:1 الي تصل ان الي 4:1 بدل الخلطة نسب غير

-if no response or still RBS > 250 or GI ration reached 4 with no Response

give insulin:

-Rules to give insulin :

1- regular insulin113

2-maintain glucose infusion to avoid abrupt change in glucose

3- measure RBS every 15 min

Methods:

A-Bolus:

- 0.1 or 0.2 unit / kg / 6 hrs IV or sc /6 hrs or 12 hrs

But this may lead to rapid drop in glucose >>>brain damage ( disadvantage )

B- infusion: 0.01:0.1 u/kg/hr

NB:10ml>>>>100u

Another rough method :infuse 5+50cm saline at arate of (the child weight/hour)

انسولين شرطهN.B: DKA >>>> 50 marks of insulin + 50 cm normal saline

NB:

-HYPOGLYCEMIA is more dangerous than hyperglycemia

- don't elevate blood glucose by D 25 as it increase the osmolarity and cause brain damage

-to infuse concentrated glucose . 12.5 % need central line as if in peripheral line >>>tissue damage

- IV glucose terminated gradually to avoid rebound hypoglycemia

- if RBS ,25 correct it 1st before feeding as may aspirate ( no coordination )

--How to give 4-8 mg/ kg / min:

e.g : 6 in 4 kg baby

1- calculate daily need of glucose = 6 x 4 x 60 x 24 = 34.5 gm / day

2- calculate fluid / day e.g 70 ml / kg = 4 x 70 =280

3-see others ( e.g Ca)

114

مثال N F = 265 ml <<< التخصيم

4- use diff. conc to reach targets

Remember : D 5% >>> 100 ml contain 5gm , D 10 >>>100 ml>>>>10 gm

D25>>>>100ml>>>>>25gm

5- measure concentration of glucose if >12.5>>>>>>>need central line

Hypoglycemia

-DEFINITION:- GLUCOSE LEVEL < 40 Mg / DL (Recently , < 25 mg )

N.B:- Early detection and TTT is essential otherwise brain damage may occur

-causes:

1- low glucose stores : premature , IUGR , asphyxia , hypothermia , meconium

aspiration ,$

2- IDM

3-sepsis

4- others : polycythemia , exchange transfusion ,drugs as propranolol ,

oral hypoglycemic

-C/P:

1- of cause as sepsis

2- absent c/p

3- non sp : tremors , jitteriness , exaggerated Moro reflex , poor feeding , irregular respiration , apnea , seizures , cyanosis , hypothermia

115

- TTT:

-most important >>good monitoring in high risk as IDM plan

-start feeding as early as possible

TTT plan

A- Asymptomatic :

glucose 25-40glucose < 25 mg / dl

-early feeding or D 10% as before Give iv D 10% -loading : 2 ml / kg at rate of 1 ml /

min then infusion(maintenance) at 5 ml / kg / hr

( 4:8 mg /kg / min )+ Begin feeding + Monitor every

30 min

B-symptomatic :

with convulsion:without convulsion :

-4 ml D10% bolus then maintenance with 5 ml / kg / hr or

6-8 mg / kg /min-Glucagon

-give 2 ml D10 % bolus by ml/min then maintainance by 5 ml /kg / hr

or 6-8 mg/ kg / min

فعال يعمل ما بإختصار

116

Glucose

- RBS > 40 or with no symptoms >> give 2cm/kg/dose of G 10% or 5 %

- RBS < 40 with symptoms especially convulsions >>> give 4cm/kg/dose

N.B:- Persistent hypoglycemia :

- continue glucose + increase concentration of IV glucose up to ( 12- 16 mg/kg/ min)

+ GI ratio + investigate

---- when to give cortisone :

If GI ration reached 12 + no improvement

give 5 mg / kg / day i.v in 2 didided doses

Hypocalcemia

Def:- Serum Ca level < 7 mg / dl ( Most important is level of ionized Ca )

Causes :

1- early onset ( 1st 3 days ) normal , preterm , IDM , asphyxia

2- late onset (end of week ) :- hypoparathyroidism , vit D deficiency , RF ,

anticonvulsant in mother

3- others : alkalosis , bicarbonate , exchange transfusion , lasix , photo , albumin

117

rapidly

C/P:- non specific>>>, apnea , seizers , jitteriness , arrhythmia

TTT: measure serum ca / ionized

- start Ca in 1st day in risky patient

- double dose

- add Ca to maintenance solution if infant on intra venous fluids ( Not done )

- most common is Ca gluconate 10 % add 2-5 ml/ kg 1 day to iv solution

- if there is c/p of it give 1-2 ml ca gluconate diluted 1: 4 in D 5% & Do :-

1- infuse very slowly

2- auscultate HR if decrease stop the infusion and continue when HR be

normal & then give maintenance on solution

3- Ca is very irritant so not to be extravasated >>> tissue necrosis

4- not by UVC >>> hepatic necrosis

5- never with Na bicarb >> Ca carbonate precipitation

Hypercalcemia )rare(

TTT:- -ttt of cause -adequate fluid -lasix

Hypotension & shockCauses:

118

C - cardiogenic :B - Distributive :A - hypovolemic :

-myocardial dysfunction as

asphyxia & myopathy

-outflow obstruction as coartication of

aorta , -arrythemia

-inflow obstruction e.g pneumothorax

-TAPVR

-sepsis-drug as muscle

relaxant

-placental hge(placenta previa)

-fetomaternal hge-twin to twin

transfusion -adrenocortical

insufficiency

C/P:

- PALLOR , METABOLIC ACIDOSIS , Low blood pressure

- Urine < 0.5 ml/kg/hr, tachycardia , poor perfusion , cold extremities with

normal core temp , tachypnea

TTT:

- reconfirm the reading & c/p

-exclude : PAD , hypovolemia , pneumothorax , sepsis , adrenocortical insufficiency

in preterm

- high mean airway pressure on IMV ( cause vc of vessels >>>decrease C.O.P )

CVP measurement 5-8 mmhg-

Lines :

1-volume replacement : albumin 10 ml/kg of 5% albumin over 20-30 min or

shock therapy

119

2-inotropes : dopamine & dobutamine & adrenaline .05 mg / kg / min up to

1 mg /kg /min

3-indomethacin:.1 mg/kg if PDA

4- hydrocortisone : 2.5 mg/kg in 2 doses 4 hrs apart if preterm with

adrenocortical insufficiency

5- sepsis :AB

Hypertension

- blood pressure > 100/ 75 in term and 80/ 45 in preterm

-infant must be at rest & cuff width should be at least 2/3 upper arm length

C/p:

tachypnea , lethargy , abnormal muscle tone , impaired renal function , congestive HF, hematruia , proteinuria , edema , seizures

Causes :

-drugs : dopamine ,dexamethazone

-stress : pain , cold

-renal :renal artery stenosis , obstructive uropathy

-coarcitation of aorta

-endocrinal : Renin-angiotensin path

-increased intracranial pressure : inrta ventricular hge , cerebral edema

TTT:120

1-drugs : - Lasix -Captopril ( 100-300 micro gm / kg/8 hrs ) in sever cases

- B-blocker: propranolol .5-4 mg / kg /day/ 8 hrs

2-investigations : -renal u/s ( IMP ) -echo for coarcitation if UL BP > LL BP

HYPERTHERMIA

Def:-temperature > 37.5 c

Causes:

-direct overheating : photo , radiant warmer

-overheated environment : increase incubator temperature , incubator in sun light , exess clothes , warm room

-infection : but more hypothermia

-dehydration fever >>>decreased fluid intake

-drug effect: PG E

Complications:

-increased metabolic rate & o2 consumption >>> increased RR, HR , fluid loss , irritability , apnea , periodic breathing , dehydration , acidosis , brain damage

Responses & c/p :

-V.D >>>sweating but less in preterm

TTT:

1- determine source :endogenous ( infection ) or exogenous

121

2-turn off any heats source & remove excess clothes

3-feeding or drink water (thirst usually )

4- sepsis work out

5-significant temp elevation

-tepid water sponge bath

-paracetamol 5-10 mg / kg / dose / 4 hrs oral or rectal

Hypotheremia

Def:- temp < 36.5 c

-normal temperature :36.5 -37.5 c -measured : best by axilla

Causes :

-heat loss to environment by 4 methods:

1-conduction: contact with cold object

2-convection : cold air circulating around body

3- evaporation : evaporation of liquid from wet warm

4- radiation :baby near but not in contact with cold object

-sepsis: lead to hypo or hyper

Complication :

1- hypoglycemia : due to increased metabolic rate to increased heat

122

2-acidosis : due to conversion of brown fat to heat & fatty acid & lactic acid ( by glucose )

3-hypoxia :consumed o2 in metabolism + acidosis cause V.C of pulmonary vessels

4-others : apathy , feeding problems , paralytic ileus , brady , IC hge , bleeding

Risk factors :

1-preterm: low brown fat , increased surface area

2-SGA

3-sick baby

TTT:

-warm slowly as rapid warming may lead to apnea , hypotension

- Rewarm at 1 c/ hr

المتابعة حاالت

بتشيلها اللي انت ودي تتابع وبتيجي وخرجت الحضانة في كانت حاالت دي .

1-take a brief history ( Name ,age , sibling , type of labour.. CS/VD , FT/PT , maternal DM, HTN ,PROM , state at birth , cause of presentation , times in

incubator )

2- Questions to mother ?

- طبيعي:- ) ؟ ايه أد كل و( صناعي وال الرضاعة

-:activity - اليوم طول نايم وال ويتحرك بيعيط123

cough , fever( infection ) -

وزنه - - examination -

a-auscultate chest

b-colors >>>pallor , jaundice ( Lab. Tests )

c- Heart , abdomen

d-umblicus care >> If pus >> anaflex powder (AB) + regular cleaning

by alcohol

Poor perfusion

C/p:- mottling, doesn't look good or washed out appearance.

Eamination: Temperature & all vitals (BP)

Lab:CBC, CRP, ABG , Culture

Radiological: CXR, Abd US (NEC) , Echo

TTT: aims to the cause:124

1-sepsis:Abs

2-cold stress: rewarm

3-hypotension: shock therapy

4-Hypoventilation: give O2

5-pneumothorax

6-NEC

7- Lt sided heart lesions as hypoplastic Lt heart syndrome

8- cutis marmorato: due to cold

Tachycardia-Normal HR :120-160 may reach 70-90 during sleep & 170-190 during cry

-transient tachy or arrhythmia or brady <15 s are begun

-see associated : tachypnea, poor perfusion, lethargy,

-causes:

1-Benign :post delivery , cold , heat, painful stimuli, drugs as

(atropine- epinephrine, aminophylline)

2-Pathology: fever, shock, hypoxia, anemia, sepsis, PDA, CHF ,

Hyperthyroidism

Bradycardia ( HR < 120 )

125

Transient bradycardia is benign if less than 15 sec

Causes: 1- defecation 2- vomiting 3-micturation

4-gavage feeding 5-suction (vagal stimulation)

6-drugs: B-blocker (inderal) – digitals – atropine

VIP : any infant with bradycardia , Ca must be stopped

Pathophysology:

Hypoxia Apnea convulsion airway obstruction air leak (pneumothorax) CHF

IC Hge severe acidosis severe hypothermia

Others causes: 1- hyperkalamia 2-cardiac arrhythmia 3-diaphragmatic hernia

4-hypothyrodism 5-hydrocephalus

Treatment

1- prevent the causative drug

2- treatment of the cause

3- in severe hypotension or arrest ……CPR

4- Atropine + Adrenaline / epinephrine

DD of tense fontanels

باستمرار نفحصها الزم اللي الحاجات من

126

1-hydrocephalus: * measure head circumference routinely

* Ask CT

2- ICH

2- CNS infection

4- brain edema : need mannitol – cortisone

NEC )necrotizing enterocolitis(

>>Very dangerous (usually fatal) disease اللي المعلومات اهم دي لكن شرحه سبق معروفه تكون الزم

Risk factors

1-prematurity 2-sepsis 3-hypoxia 4-overfeeding 5-ischemia

Diagnosis : by a triad of

1-distension 2-metabolic acidosis (by ABG) 3- thrombocytopenia (by CBC with differentials )

By CXR : pneumonitis intestinalis ( air in wall of intestine )

TTT:

كل وشيل الرايل افتح و يوم 14-7 لحد محاليل وكمل فورا الرضاعه اوقف حاجه اهم جوه اللي

127

Combination of (Vanco , Meronam , Flagyl , Diflucan) زيstrong antibiotic ادي

ICH )intracranial hge(

- Very serious disease that lead to death or cp ,has very bad prognosis

- Once suspected>>ask CT

- These are the most important signs:

1-pallor

قليلة أصال النيونيت فى الدم كميه ان اال قليله فقدت اللي الدم كميه ان من بالرغم ( 85 X وزنه )

2-convulsions

3- tense fontanels VIP

4-signs of lateralization :- tonicity in one side - unequal pupils

5-neck rigidity

6-opisthotonus

- Need immediate konakion - diacenon – kapron + see your text

Neonatal edema

- Common especially in preterm

128

- Common causes :

1- Sepsis2- Prematurity 3- Delay or decrease dose of aminovein االشهر 4- Renal failure : either

1- prerenal >>> hypotension 2- renal problem3- post renal obstruction

How to manage :

1- النهم واالمينوفين االميكين اوقف nephrotoxic

2- ask u

rea ,creat. + Na , K

3-press on urinary bladder >> why

يبقى بالضغط بتفضي ومش كده كورة لقيناها لو post renal obstruction

يكون ممكن ده بالضغط بتفضي لقيناها لو اما (renal, pre renal, atonic bladder) in H.I.E cases >>

4-give challenge test>>> shock therapy +lasix ( if urine come , the cause is prerenal )

5-measure blood pressure

6-give plasma / 12 hr >> to increase osmolarity

ال حاالت فى edemaال pre renal ال بتاخد fluid لل tissue عنده الواد وبالتالى masked hypovolemia ومحتاج fluids هو سبب اشهر وعامه الضغط نقيس الزم وطبعا

نقصاالمينوفين

Down syndrome129

* How to suspect? The most important signs are

1-low set ears >>

ال من خط بأخذ ونعرفها medial canthus ال وليس lateral canthus ثابته مش عشان يبقى اقل االذن مستوى لو لألذن ده الخط وتوصل low set ears

2-wide spaced medial canthus + epicanthus

3- simian crease.

4-wide space between 1st & 2nd toe.

NBs from PracticeThere are notes I learned from actual practice:

Shift 1

- 11 infant at my 1st shift (3 Vent, 1 Postvent, anemia, jaundice, pnemothorax,☺

-frequent sampling is the most common cause of neonatal anemia

-to follow up jaundice : ask TSB/ DSB every other day.

-anemic baby better to be fed by Ryle even suckling is good as it is effort for him

-baby who give residual digested >> give it to him & see how much( < or> 10%) & mange as before

-Brownish secretions from stomach before starting feeding isn't contraindication for feeding

رضاعة وابدأ زانتاك وأدى ونضيف رايق مايبقى لحد جدا كويس معدة غسيل اعمل -وادى( 6سم/2خفيف) على بالرايل الرضاعة ادوية ساعات

-anemia>> hemic murmur130

يدفوه... دا الكالم ألمه اقول لذا( 6) وجهه على ظاهرة والصفرا العيل تخرج احيانا -افضل الحضانة فى يخلوه او كويس

ال على العيال متابعة - vent بعمل x-ray ال واشوف areation, pneumonia ال واعيد ABG

ال من خايف لو - ETT ... ركب Ryle للحماية االول

- ال على من يتأف ينفع الطفل هل تشوف تيجى لما << vent النص الى الدورميكيم قلل ال واشوف الجهاز على يصحى ما لحد RR بال انزل ابدأ كويس لو setting على واحطه

A/C ثم CPAP ثم NASAL

- العيال: ال هام PTوعلى Vent معاهم وادى وبالزما دم هيحتاجوا غالبا داخلين ولسه واعمل كوناكيون CBC, CRP وجود فى خاصة ecchymosis وال X-ray طبعا

- اعمله تخرجه عايز اللى الصفرا عيل Double وحلله

- هام فالجيل Post vent ال عشان Anerobes

- على التحكم hypoactive وبالتالى sepsis واخد عيل فى Sedation

** The worest experience (Pneumothorax)

-Case: 28 Ws baby ,2W bad chest put on IMV but extubated early (W2 RR 63) &put on CPAP then nasal then RD reappear & vent was decided.

-After intubation &from 1st air pressure>>sever cyanosis(sudden) , abd distension ,no HT heared, no airentry, no expansion ,decreased perfusion & baby

gasping>>> CPR (chest compression, adrenaline, bicarb, shock therapy)>>no RR( pnce suspected pneumothorax) >>bilateral Butterfly >>air was muchthen the

baby suddenly become pink with good condition.

-Then pulmonary Hge occurred>>given konacion , Dicynon , Kapron , asked plasma, Bicarb, +Vent with (PIP 25, Time 3, PEEP 3, FIO2 100)

-The chest cannula was done + butterfly

New case of RD:

1-Examination & auscultation

2- good aspiration

131

3-may give Na bicarb empirical 4- solutions

Shift 2

- امتى: 1 سم؟؟؟10 بعد حتى ببرونة وماابدأش الرايل على استنى هام -Anemia 2-RD

- على ماتحكم قبل X-ray ال من بالك خد Quality ال وشوف Gases سودا مش لو (Jet black) االشعة تبقى Soft

الحاجة حسب وامينوفيليين ديكسا 2 اعطى post vent >> :هام-- UVC >>below costal margin >> in CXR

- Indication of off vent: 1-clinical: color, RR , auscultation 2-ABG >>> on CPAP 3-CXR

- فى: سخونية,, حاالت هام فالطفل اذن وصفر كويس ومابيرضعش كتير بينام و المتابعةsepsis مسبتك

- ب ونفكه امساك تعمل االعشاب glycerin

ال لو Ca التعطى- HR بيعمل النه120 من اقل Bradycardia

Shift 3

- In Premature 29 Ws >> if TSB 10 >>it is too high

- If RBS is low>>> suspect solutions mistakes

- ال حاالت فى خاصة فجأة السومونليتا اليوقف convulsion مايحصلش عشان - Rebound

-start w2 1.5 aminovein if edema or Preterm

- الحالة ان األهل مع قوى ركز - male or female

-if acase aspirated by milk >> do CRP & shift to Ryle

132

- Distension avoided by prophylactic drugs

- In x-ray take care of collapse as it simulate pneumonia but clinically pneumonia presented by tachypnea & retraction

- c/p of pneumonia>>tachypnea & retraction

العالج الن موجودين لسه دول لو األكسجين توقف وممكن ABs

- Jaundice high for ling time >> Retics &suspect ABO, or Rh

كيلو 1.5 يوصل الطفل لما ترضع االم - + Full amount -

Shift 4

+ Preterm on IMV -1 كتير بيصحى

على مستريح الولد لو IMV هـيــ مش fight واخد مش لو حتى sedative أما وهيدعيلك وبيـ بيصحى لو fight اما يكون ممكن اللى كدة عامل اللى السبب على ندور hypoxia أو ال جرعات راجع sedative شوية ونقللها

2- preterm who are 1 kg or less

من االقف فى فى علية تستعجلش ما IMV على نقف..... تقف ولما nasopharyngeal CPAP

3- in CPAP → PEEP do not exceed 7 + F1O2 do not exceed 70%

كدة من اكتر retraction + decreased saturation+ ....... على العيل تحط الزم

mechanical ventilation ونقلل FiO2 (low sitting) ال علشان Retinopathy

4- take care of retionpathy in preterm so low setting is better is increase saturation

PIP 16 Fi O2 40% PEEP 3 time 0.36 rate 40:35 inspir/respir 1 : 3

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ال محققة اللى من بالك تاخ الزم المهم -5 ventillator علية ظابتة انت اللى مش

ال يعادل علشان رينجر 10 ادى تانى عيل تفنتل لما -6 acidosis الى بيتحول النة HCO3 على تحطة وممكن a\c متديش علشان sedation

نفسها تشوف علشان االكسجين كل من اتقفت تكون الزم هتخرج اللى الحالة -7

او اتروفينت اكتب كانيوال مفيش ولو ديكسا اكتب وحش صدرها اللى الحالة -8 pulm.cort

9- pulm cort ( Beclomethazone ) :- inhalation long acting steriod

ال علشان مناسب غير ودة neonate بيزود ألنه chest infection هو منة واالحسن atrovent االتروفينت

10- Hepatomegally is present with UVC

ال اوقف علشان -11 photo اعمل الزم TSB & DSB يوم و يوم

حاالت هاااااااااام -12 preterm + oedema

Causes: 1- prematurity or decreased aminovien 2- sepsis

3- renal failure( prerenal / renal / postrenal )

Treatment:

1- 1st do urea and creatinine

2- ask for plasma \ 12 hours to increase osmolarity

فى هيكون الواد هنا hypovolemic shock ال من بالرغم oedema ال الن عنة اللى fluids ال برة موجوة vessels ال فى وموجودة tissue ازاى منها نتاكد وهنا

A - bood preassure is low

B - challenge test shock therapy + lasix >> infant urinate

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3- stop amikin & aminovein NOW

4- detect if infant urinate or not ?? IF no urine >>

2- empty bladder1- full bladder

ال - فاضية bladder هتحس هتالقيهابول هتجيب مش عليها وهتضغط

ال نعمل challenge test وبالتالىفيه ان يعنى وهذا

renal failure ( pre renal or renal causes)تسمى - Atonic bladder ودى

ال - bladder distended هتالقىيعنى - ودة ايدك تحت كورة وهتحس

فية obstruction انقسطرة - يتركبلة الزم دة والطفلبول

ال تعوض الزم circulation 5 بال ة للعيل - shock therapy

6 علشان بوتاسيوم و صوديوم تحليل عمل اطلب - hyperkalamia

اعمل لحد دم تنقل ما قبل -13 Hb ال علشان pallor .. ال سببة يكون ممكن hypoxia الهيموجلوبين ويكون

مسلي % 5 جلوكوز سم24+ ادرينالين الطفل وزن قد)) هى adrenaline infusion جرعة -14

معدل على

1 ساعة 24 فى الساعة\ سم ))

15- Treatment of BPD is steroid , lasix , amionphyline

16- In x-ray if you find apical patch it should not be pneumonia and it may be collapse

As pneumonia need: 1-tachypnea and chest retraction

2-if broncho (patchy) or lobar take whole lobe

+ If collapse shift of mediastinum.

17- cases of HIE have POOR Prognosis>> hypoactive , spastic ( detect grade 1,2,3 )

+ tense fontanels +THC brain oedema135

+ pale due to hypoxia not due to anemia

Treatment >> rest 30% + manitol (brain edema)

Do CT You find brain edema and IC Hge ( appear white )

Or may be calcification which apear in neonate especially if there is congenital

infection.

Shift 5

1- if child is blue with feeding , it may with infection and must do chest x-ray

رايل ادى الرضاعة مع بيعلى نفسه الولد لو -2

اى اكتشفت لو -3 trauma الجامعة على حول

ال على تشيك دايما -4 temperature

ال على تشيك دايما -5 flow meter هتعمل قلت المياة لو علشان dry air

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العالمين رب لله الحمد

في المشاركين لجميع الدعاء نسألكمالعمل هذا