6
- Grunting respirations
- retractions
- nasal flaring
- cyanosis
- increased oxygen requirement after birth
Clinical manifestations of RDS
- Most common single cause of respiratory distress in neonates
- 10% of all premature infants in the US
- Increases to 50% to 60% for infants born less than 29 weeks of gestational age
- pathophysiology - pulmonary immaturity and low production of surfactant
- antenatal steroids to accelerate lung maturation <34 weeks reduces incidence and decreases mortality
Respiratory distress syndrome
(Hyaline membrane disease)
- Cardiopulmonary bypass
- Immature lungs rest and recover to avoid effects of mechanical ventilation
- Heparin - increased risk of systemic and intracranial hemorrhage
- at least 34 weeks of gestational ages
- weigh more than 2000 g
- no evidence of intracranial bleeding
- require less than 10 days of assisted ventilation
- reversible lung disease
- limited to no PT intervention due to bleeding risk
ECMO
- Patent ductus arteriosus (PDA)
- Pulmonary atresia
- Tetralogy of Fallot (TOF)
- Coarctication of the aorta (COA)
Cardiac issues with neonates
IVF grading scale:
Hemorrhage that spreads into the periventricular white matter
Grade IV
- High risk neonates frequently demonstrate impairments: muscle tone, ROM, sensory organization, postural reactions
- Impairments in body functions and structures may contribute to limitations in activity such as: difficulty in breathing, feeding, visual and auditory responsiveness, motor activities such as head control and movement of hands to mouth
- The interaction between impairments and activity limitations may contribute to restrictions in parent-infant interaction (participation)
ICF model of care
- Respiratory distress
- early: onset respiratory distress int erm and near term infants
- Positive: pressure ventilation is contraindicated
- Antibiotic until bacterial infection is ruled out
- hypersensitive to environmental stimuli and treated in quietest environment possible
- surfactant administration may reduce the severity and decrease the number of infants requiring ECMO
- Approximately 20% of infants will have neurodevelopmental delays up to 3 years of age even if responded well to conventional treatment
Meconium aspiration syndrome (MAS)
- Oxygen supplmentation
- assisted ventilation
- surfactant administration
- Extracorporeal membrae oxygenation (ECMO)
- Continuous positive airway pressure (CPAP)
- positive and expiratory pressure (PEEP)
- mechanical ventilation
Treatment for RDS
- About 45% of infants with birth weights between 500-750g
- About 20% of infants with birth weights <1500g
- Most occur within the first 48 hours after birth
- Diagnosis is based on routine or symptom-driven screening through cranial ultrasound
- Risk factors that can disturb cerebral blood flow include: vaginal delivery, low apgar scores, severe respiratory distress syndrome, pneumothorax, hypoxia, hypercapnia, seizures, patent ductus arteriosus, thrombocytopenia, infection, mechanical ventilation
Intraventricular hemorrhage (IVH) and periventricular hemorrhage
IVF Grading scale:
hemorrhage isolated to the germinal matrix
Premature infants with which grades of IVH are at risk for neurosensory impairment, developmental delay, CP, and deafness at 2-3 years of age
I-II
- Range from subtle and nonspecific to catastrophic
- Clinical signs: abnormalities in level of consciousness, movement, muscle tone, respiration, and eye movement
- catastrophic deterioration: major acute hemorrhages, stupor progressing to coma, respiratory distress progressing to apnea, generalized tonic seizures, decerebrate posturing quadriparesis
S/S of IVH ***
- Death
- Poor neurologic outcomes
- Abnormal somatization and response to pain later in life
Adverse sequalae to pain in babies
More severe IVH, especially which grade will the risk of CP be present in up to 39% of patients and hydrocephalus in up to 37%?
Grade IV
IVF grading scale:
Normal sized ventricles that occurs when hemorrhage in the subependymal germinal matrix ruptures through the ependyma into the lateral ventricles
Grade II
- Pain behaviors
- Physiologic change
- Changes in cerebral blood flow
- Cellular and molecular changes in pain-processing pathways
Expressing pain in babies
- Prenatal care aiming at reducing premature birth
- antenatal steroids to reduce severity and incidence of severe symptoms
- indomethacin- used to close patent ductus arteriosus
- close monitoring and management of ventricular dilation
- physiologic support to maintain oxygenation, perfusion, body temperature, and blood glucose level
- management of ventricular dilation: ventriculoperitoneal shunting, temporary ventricular draining
- physical handling is minimized
IVH
Peripheral nervous system capable of responding to stimuli by ___ weeks gestational age
20 weeks
Number and types of peripheral receptors similar to adults by ________ weeks of gestation?
20-24 weeks
IVF grading scale:
Acute ventricular dilation
Grade III
- Increased density of receptors in newborn compared with adult
- spinal cord and brain stem tracts not fully myelinated (messages are slower)
- Pain pathways, cortical and subcortical centers of pain perception, and neurochemical systems associated with pain transmission functional in 20-24 weeks gestational age
Pain
- Increased HR
- HR variability
- BP response
- Increased respiration
- Decreased oxygenation
- Skin color and character include pallor or flushing, diaphoresis, and palmar sweating
- Increased muscle tone
- Dilated pupils
- Laboratory evidence of metabolic or endocrine changes
Physiologic manifestations of pain
- Decreasing the number of noxious stimuli
- decreasing stimulation
- swaddling
- nonnutritive sucking
- Tactile comfort measures
- rocking
- containment
- music
Nonpharmacologic methods to alleviate pain in the NICU
Pain modulatory tracts, which can inhibit pain through release of inhibitory neurotransmitters such as serotonin, dopamine, and norepinephrine, not developed until _____ weeks of gestation?
36-40 weeks
- Sustained and intense crying
- Facial expression of grimaces
- Furrowed brow
- Quivering chin
- Eyes tightly closed
- Motor behavior such as limb withdrawal
- Thrashing
- Rigidity
- Flaccidity
- Fist clenching
- Finger splaying
- Limb extension
Behavioral responses to pain