早产儿常见之问题.pptx

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,早產兒常見之問題(1),IVH,(intraventricular hemorrhage):腦室內出血,PVL,(periventricular leukomalacia):白質軟化症,ROP,(retinopathy of prematurity):早產兒視網膜病變,RDS,(respiratory distress syndrome):呼吸窘迫症候群,早产儿常见之问题专家讲座,第1页,早產兒常見之問題(2),BPD,(bronchopulmonary dysplasia):支氣管肺發育不全,NEC,(necrotizing enterocolitis):壞死性腸炎,PDA,(patent ductus arteriosus):開放性動脈導管,早产儿常见之问题专家讲座,第2页,Gestational age estimation and birth weight classification,Infant are classified by GA as,Preterm(37 weeks),Term(37-41 6/7 weeks),Postterm(42 weeks or more),Birth weight classification,Normal birth weight(NBW):2500 gm or more,Low birth weight(LBW):2500 gm,Very low birth weight(VLBW):1500 gm,Extreme low birth weight(ELBW):result functional closure commonly occurred within 12 hours in full term baby,Second stage,:connective tissue formation and replacement of muscle fibers with fibrosis-ligmentum arteriosum,Both,PGE2,and,PGI2,relax the ductus arteriosus,早产儿常见之问题专家讲座,第17页,Incidence,Prematurity:inverse with GA,PDA is found in about 45%of infant under 1750g and 80%in infants weighting fall in pulmonary vascular resistance and a rise in systemic resistance,if PDA opened left to right shunt(+),-result in increased pulmonary blood flow,left ventricular,volume overload,increased left ventricular end-diastolic volume and pressure-,CHF,早产儿常见之问题专家讲座,第19页,Pathophysiology,Renal,mesenteric and cerebral blood flow decreased due to,ductal steal,These with moderate and large ducts are prone to the development of,pulmonary vascular obstructive disease by 1 year of age,or beyond,Preterm infant may develop CHF,earlier,because of incomplete development of the,medial musculature,in the small pulmonary arterioles,Among those with,RDS,they may be a initial period of improvement as the pulmonary status improves,早产儿常见之问题专家讲座,第20页,Clinical findings(Term infants),Pulmonary vascular resistance determines the clinical manifestations:,A continuous murmur is heard infrequently,Large PDA has,1.bounding peripheral pulse pressure,2.wide pulse pressure(difference between systolic and diastolic pressure),3.hyperactive precordium:due to elevated stroke volume,早产儿常见之问题专家讲座,第21页,Clinical findings(Term infants),4.Hypotension particular in these of ELBW,5.Heart failure in large PDA doesnt develop until,3 to 6 weeks,of age,Associated with pulmonary disease,left heart obstructive lesion and coarctation of aorta,pulmonary resistance may be high-right to left shunt-no murmur,早产儿常见之问题专家讲座,第22页,Clinical findings(preterm infants),1.The same clinical sign as term baby,2.However,many preterm baby with large PDA have no murmur,3.Most will have an increased pressure,早产儿常见之问题专家讲座,第23页,Diagnosis,Chest x ray,:cardiac enlargement,pulmonary plethora,a prominent main pulmonary artery and left atrial enlargement,EKG,:left ventricular hypertrophy,left atrial hypertrophy,Echocardiography,:,1.M-mode:normal,LA:Aa ratio,in infants is between 0.8-1.0,A ratio 1.2 suggests left atrial enlargement(in the absence of left ventricular failure or volume overload),2.2-D:PDA,早产儿常见之问题专家讲座,第24页,Treatment,Term infants:No evidence of cardiovascular embarrassment should be followed and,catheter closure,or thoracoscopic or surgical diversion,Digoxin and diuretics,for PDA with CHF,早产儿常见之问题专家讲座,第25页,Preterm infants,1.Ventilator support and fluid restriction,2.,Indomethacin,treatment produces closure in 85%of patients,3.,Prophylactic,administration of indomethacin early after birth in,very premature infants(1250 g),decreased the incidence of PDA,CHF,IVH and possibly mortality-but,not routine,due to the risk of leukomalacia,decreased renal function,platelet function and NEC,早产儿常见之问题专家讲座,第26页,Preterm infants,4.Ibuprofen(10 mg/kg)may have fewer side effect,.,Archives of Disease in Childhood:Fetal&Neonatal Edition.76(3):F179-84,1997 May.,(ibuprofen did not significantly reduce mesenteric and renal blood flow velocity.),Journal of Pediatrics.135(6):733-8,1999 Dec.,5.Blood transfusion,in anemic preterm baby diminishes the left ventricle volume overload and hasten ductus closure by,increasing arterial oxygen content,早产儿常见之问题专家讲座,第27页,Preterm infants,Early,indomethacin,treatment(in premature infants with respiratory distress syndrome),improves,PDA,closure but is associated with,increased renal side effects,and more severe complications and has,no respiratory advantage,over late indomethacin administration in ventilated,surfactant-treated,preterm infants 32 weeks gestational age.,(Journal of Pediatrics.138(2):205-11,Feb.),早产儿常见之问题专家讲座,第28页,PDA,Coil occlusion,is a safe and effective method of percutaneous closure of small to moderate-size,(minimum diameter or=4 mm),PDA,s.,The largest,PDA,that can be closed with this technique remains to be determined.,Journal of Pediatrics.130(3):447-54,1997 Mar.,早产儿常见之问题专家讲座,第29页,Age of onset of treatment,IV dosage(mg/dl),1st,2nd,3rd,12-24 hours,4,th,dose or 2nd course,7 days,0.2,0.25,0.25,早产儿常见之问题专家讲座,第30页,Contraindications for indomethacin,1.serum creatine 1.7 mg/dl,2.Frank renal or gastrointestinal bleeding or generalized coagulopathy,3.NEC,4.sepsis,早产儿常见之问题专家讲座,第31页,Necrotizing enterocolitis,(NEC),早产儿常见之问题专家讲座,第32页,Necrotizing enterocolitis,1.Definition2.Incidence3.Pathology&Pathogenesis4.,Clinical manifestations5.Diagnosis,6.,Management7.,Complication,早产儿常见之问题专家讲座,第33页,Definition,The most common,life-threatening emergency,of the gastrointestinal tract in the,newborn,stage.,An,acquired,neonatal disorder characterized by various degrees of,mucosal or transmural necrosis,of the intestine.,早产儿常见之问题专家讲座,第34页,Incidence,Decreased,birth weight,&,gestational age,incidence&fatility,Rare in term infants.,Overall mortality,20 40%.,Neonatal ICU,1 5%,No,association with,or,race.,Occures,sporadically,or in,epidemic clusters.,Most involved the,distal part of the ileum,and the,proximal segment of colon,.,早产儿常见之问题专家讲座,第35页,Pathology&Pathogenesis(1),Cause:remains,unclear,but is,multifactorial.,No proven cause,has been estabilished.,The greatest risk,Premature,Interactions between,mucosal injury,(ischemia,infection,inflammation)and the,hosts response to the injury,(circulatory,immunologic,inflammatory),早产儿常见之问题专家讲座,第36页,Pathology&Pathogenesis(2),Clustering of the cases,infectious agent,(E.Coli.,Klebisella,Enterobacter,Salmonella,Coronavirus,Rotavirus,Enterovirus),No,pathogen is identified.,Rarely occures before,enteral feeding.,Much less common in infants fed,human milk.,Triad,intestinal ischemia,oral feeding,pathogenic organisms,早产儿常见之问题专家讲座,第37页,Initial,ischemic,or toxic,mucosal damage,Loss of mucosal integrity,Enteral feedings,+,Bacterial proliferation,Necrosis of the intestine,Gas accumulation in the submucosa of bowel wall,(,penumatosis intestinalis,),Transmural necrosis or gangrane,Perforation,Sepsis,Death,早产儿常见之问题专家讲座,第38页,Clinical manifestations,A variety of signs and symptoms and may be onset insidiously or suddenly.,Usually occurs in the,first 2 weeks,.,Age of onset,is inversely,relatede to the gestational age(VLBW,3 month).,First signs:,abdominal distension,with,gastric retention.,25%,bloody stool,Progress maybe be,rapid,but unusually to progress from mild to severe after,72 hr,.,早产儿常见之问题专家讲座,第39页,Signs and symptoms associated with necrotizing enterocolitis,Gastrointestinal,Abdominal distention,Abdominal tenderness,Feeding intolerance,Delayed gastric emptying,Vomitting,Occult/gross blood stool,Change in stool,pattern/diarrhea,Abdominal mass,Erythema of abdominal,wall,Systemic,Lethargy,Apnea/respiratory distress,Temperature instability,Acidosis,Glucose instability,Poor perfusion/shock,DIC,Positive results of blood culture,早产儿常见之问题专家讲座,第40页,Diagnosis,A very high index of suspicion in treating infants at risk is essential.,Clinical triad:,Feeding intolerance,abdominal distention,grossly bloody stools.,Lab studies:CBC,electrolytes,blood culture,stool screening,stool culture,Radiologic studies:,1.X-ray of abdomen:,Pneumomatosis intestinalis,(50-75%),Portal venous gas,2.Hepatic ultrasonography,早产儿常见之问题专家讲座,第41页,KUB demonstrating abdominal distention,hepatic portal venous gas,(arrow),and,bubbly appearance of pneumatosis intestinalis,(arrowhead).The latter two signs are pathognomonic for NEC.,早产儿常见之问题专家讲座,第42页,Intestinal perforation,.Cross-table abdominal roentgenogram in a patient with NEC demonstrating marked distention and massive,pneumoperitoneum,as evident by the free air below the anterior abdominal wall.,早产儿常见之问题专家讲座,第43页,Management,Basic NEC protocol:,1.Nothing by mouth(,NPO,),2.Use of a,nasogastric tube,3.,Antibiotics,4.Monitoring of vital signs&abdominal circumference,5.Removal of the umbilical catheter,6.Monitoring of,fluid,intake and output,7.Monitoring for gastrointestinal bleeding,8.Laboratory monitoring,9.Septic workup,10.,Radiologic,studies,早产儿常见之问题专家讲座,第44页,Management by,Stages,Classified by,clinical syndrome,(1986 Walsh and Kliegman),Stage I:Suspected NEC,Systemic:Nonspecific,apnea,bradycardia,and temperature instability,Gastrointestinal:Increased gastric residuals Occult blood stool,Radiographic:Normal or nonspecific,Treatment:NPO with antibiotics for 3,days,早产儿常见之问题专家讲座,第45页,Stage II A Mild NEC,Systemic:,Nonspecific,similar to stage 1,Gastrointestinal:,Absent bowel sounds,and,Gross blood stools.,Radiographic:,Ileus,with dilated loops,focal areas of pneumatosis intestinalis,Treatment:,NPO,with,antibiotics,for,10-14,days,早产儿常见之问题专家讲座,第46页,Stage II B Moderate NEC,Systemic:Mild metabolic acidosis and,mild thrombocytopenia,Gastrointestinal:,Tenderness,abdomianl,wall edema,palpable mass,Radiographic:,Extensive pneumatosis,portal venous gas,early,ascites,Treatment:Similar to stage II B,早产儿常见之问题专家讲座第47页,Stage III A Advanced NEC,Systemic:Hypotension,bradycardia,respiratory failure,coagulopathy,severe metabolic acidosis,Gastrointestinal:,Spreading edema,erythema,induration of the abdomen,Radiographic:,Prominent ascites,Treatment:paracentesis,fluid resuscitation,inotropic agent support,ventilator support,.,早产儿常见之问题专家讲座,第48页,Stage III B Advanced NEC,Systemic:Deteriorating vital signs,shock,electrolyte imbalance,Gastrointestinal:,Perforation of the bowel,Radiographic:,Perforation of the bowel,Treatment:Surgical management,早产儿常见之问题专家讲座,第49页,Surgical m,anagement,Indication for operation:,1.Evidence of intestinal,perforation,2.A spersistent,fixed,senile loop,3.,Erythema,of the abdominal wall,4.A,palpable mass,5.,Brown paracentesis,fluid with organisms on Gram stain,6.Failure to response to medical treatment.,早产儿常见之问题专家讲座,第50页,Prognosis,Pneumatosis intestinalis:,20%,fails in medical management,9-25%,die.,About,75%,of all patient survival,50%,develop a long-term complication,The 2 most common complications are,intestinal stricture,and,short-gut syndrome,.,早产儿常见之问题专家讲座,第51页,Complication(1),Intestinal stricture,:,1.Occur in,10%,of patirnts.,2.Diagnosed by barium enema,3.S/S:feeding intolerance and bowel,obstruction occur,2-3 weeks,after,recovery from the initial event,4.Tx.:Resection of the affected portion.,早产儿常见之问题专家讲座,第52页,Complication(2),Short-gut syndrome,:,1.Most in patients lost most of the small,bowel or portion of the,ieocecal valve,.,2.S/S:,Malabsorption,growth failure,malnutrition,3.Take 2 years for the gut to grow and adapt.,4.Follow the nutritional condition.,早产儿常见之问题专家讲座,第53页,牛刀小試?!,早产儿常见之问题专家讲座,第54页,1.以下有關腦室內出血(Intraventricular hemorrhage)之敘述何者正確？,A.病嬰大多有出血後水腦症(posthemorrhagic hydrocephalus),B.肌張力增強,C.大部分於初生時就發生,D.1015%屬於遲發性出血,早产儿常见之问题专家讲座,第55页,2.以下何者非早產造成併發症？視網膜病變,腦室內出血及腦室周邊白質軟化症,開放性動脈導管,胎便吸入症候群,早产儿常见之问题专家讲座,第56页,3.有關生出早產兒危險原因，何者有誤？,母親年齡輕,產道感染,羊水過多,胎兒有心臟病,早产儿常见之问题专家讲座,第57页,4.關於PDA之敘述，何者不正確？,男與女之發生率為1:2,Indomethacin 能够治療PDA,心導管能够治療PDA,Prostaglandin E 能够治療PDA,早产儿常见之问题专家讲座,第58页,5.有關PDA之敘述，何者有誤？,PDA病人之心雜音為pansystolic murmur,為早產兒常見之問題,早產兒PDA可用indomethacin使之關閉,三個月嬰兒使用indomethacin仍會有效地關閉PDA,早产儿常见之问题专家讲座,第59页,6.有關新生兒壞死性腸炎之敘述何者,錯誤,?,(A)易發生於低體重之早產兒,(B)早期症狀為腹脹,血便及胃排空不良,(C)X光檢查可見到腸壁積氣 (pneumomatosis intestinalis),(D)外科手術為唯一治療方式,早产儿常见之问题专家讲座,第60页,7.哪一項,不是,新生兒壞死性腸炎特點?,(A)最多發生位置在distal ileum and proximal colon,(B)常發生於出生兩星期內極低體重兒,(C)腹部X光顯示pneumomatosis intestinalis,(D)死亡率高達40以上,早产儿常见之问题专家讲座,第61页,8.有關新生兒壞死性腸炎,以下何者正確?,(A)病兒一定有危險因子,如先天性心臟病,(B)一旦有懷疑,應马上進行手術,(C)驗糞便潛血反應對診斷沒有幫助,(D)末端迴腸是最好發部位,早产儿常见之问题专家讲座,第62页,9.壞死性腸炎手術後產生之併發症中,不,包含以下何者?,(A)腸道狹窄,(B)短腸症候群,(C)細菌感染,(D)肝門靜脈高壓,早产儿常见之问题专家讲座,第63页,