Download DeVoe

Mike Devoe, MD
7/31/2010
Dr Mike DeVoe
D Mik D V
NE TN Regional Perinatal Center
Now. Minimum 2 page order set
Are we being inundated with preterm infants?
y Regional Perinatal Center data, 2007
y Regional Births, TN 5225 VA 3245
y LBW Births TN 525+ VA 360+
y NICU
y 500 + admissions 2009
y ALOS – 17 days
y Trends
y
y
y
Increased admissions for Neonatal Abstinence Syndrome (NAS)
Preterm delivery rate unchanged
Increase in “Late Preterm” rate
2007
2007
2007
TEENAGE
2007
2007
LBW
2007
VLBW
INFANT MORT.
# BIRTHS
PREG. RATE
Unmarried
%
#
BUCHANAN
202
30.9
79
16
7.9
6
3.0
1
5.0
DICKENSON
203
26.2
63
22
10.8
6
3.0
GRAYSON
157
26.3
55
16
10.2
1
0.6
2
12.7
CITY/COUNTY
LEE
#
%
265
36 9
36.9
86
15
57
5.7
NORTON CITY
45
36.7
23
6
13.3
RUSSELL
298
11.1
84
20
6.7
04
0.4
3
11 3
11.3
2.0
5
16.8
SCOTT
207
21.6
2
9.7
351
30.6
144
43
12.3
5
1.4
4
11.4
468
25.5
159
48
10.3
7
1.5
2
4.3
22
183
8.7
1
6
SMYTH
551
18
RATE
TAZEWELL
WASHINGTON
69
#
8
10
3.9
47
8.5
WISE
498
32.6
190
56
11.2
10
2.0
3
6.0
SW VA Region
3245
27.3
1135
307
9.6
60
1.8
1.8
25.0
3
7.5
5.4
VIRGINIA
107,261
27.2
38,281
9,344
8.6
1,899
1.7
760
7.7
Mike Devoe, MD
7/31/2010
TEENAGE
COUNTY
# BIRTHS PREG. RATE
ADEQ. PRE-
LBW
VLBW
INFANT MORT.
Unmarried
NATAL CARE
#
%
#
%
#
RATE
CARTER
561
20
38.3
68.6
52
9.3
9
1.6
2
3.6
GREENE
753
30.2
41.7
65.7
53
7.2
9
1.2
2
2.7
HANCOCK
86
6.6
25.6
70.9
11
12.9
1
1.2
-
*
HAWKINS
635
22.3
36.9
64.1
45
7.3
6
0.9
4
6.3
JOHNSON
188
32.2
35.1
71.8
18
9.6
7
3.7
2
10.6
SULLIVAN
1707
32.3
41.8
66.2
168
9.8
35
2.1
20
11.7
UNICOI
180
19.9
37.2
70.0
13
7.2
4
2.2
3
16.7
WASHINGTON
1415
25.1
36.2
75.3
128
9.0
24
1.7
14
9.9
36.6
68.9
488
9.0
95
1.7
47
8.5
27.8
42.8
60.9
8176
9.4
1514
1.7
718
8.3
NE TN
REGION
5525
TENNESSEE
86661
Outcomes
y Vermont Oxford:
y International outcomes database, > 800 NICU’s
y Comparative outcomes to similar size and complexity NICU
y State comparisons available through TIPQC state data reporting subset through Vermont Oxford
y “real‐time” outcomes available on line
y Annual summaries for planning, y
Identifying the outliers
And how are we doing locally?
(What are “our” problems we are turning over to you?)
y How do we know our outcomes?
y What are our goals?
y What factors hinder accomplishment of our goal of optimal outcomes
i l y Subspecialty access
y
Ophthalmology, neurology, orthopedics
y Funding issues
y
Some insurers will not reimburse for follow‐up
y “Lost to Follow up”
Mike Devoe, MD
7/31/2010
With all of the improvements in NICU care like surfactant, improved ventilation strategies, why are we still seeing “BPD”
BPD/CLD: Proposed Etiologies
Normal Lung Development
y Pulmonary Immaturity
y Oxygen Toxicity
y Barotrauma/Volutrauma
y Vitamin Deficiencies
y Failed Antioxidant Protection
y Genetic Predisposition
y Excess Fluid Administration
y Patent Ductus Arteriosus
y Chronic Infection
y
y
y
Canalicular Period
16 to 26 weeks
Saccular Period
26 to 36 weeks
Ureaplasma
Chlamydia
Cytomegalovirus
Alveolar Period
36 to 41 weeks
(Non‐human, Primate Lung Sections)
Presented by K Stenmark, MD:ICRV, 2003
Incidence of BPD/CLD
y Worldwide, the incidence of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD) is reported to range from 14% to 43% of premature infants, depending on population studied.
y The incidence of CLD/BPD is inversely related to birth weight and gestational age.
y Definitions vary greatly, and this has made estimates of disease incidence difficult to ascertain.
Fanaroff AA, et al. Am J Obstet Gynecol. 1995;173:1423‐31
CLD: Clinical Manifestations
y Symptoms of CLD:
y Chronic, recurrent pulmonary exacerbations
y Cough
y Wheeze
y Tachypnea y Respiratory distress
Mike Devoe, MD
CLD: Typical Chest X‐ray Findings
Radiographic Abnormalities of Chronic Lung Disease (CLD):
Hyperinflation
Hazy appearance consistent with fib i /i t titi l fibrosis/interstitial changes
Linear‐reticular opacities
Cystic elements (emphysematous bullae)
Scoring systems vary from institution to institution
CT scans are thought by some to be better than plain films for diagnosis and monitoring changes
7/31/2010
NICU Discharge management
y Oxygen requirement stable for 1 wk prior to discharge
y Low flow 100% cannula system for home use
y Optimal diuretic therapy, chlorthiazide and aldactone
y Bronchodilator therapy as needed
y Inhaled steroid therapy as needed
I h l d id h
d d
y No immediate medication changes for several days prior to discharge
y Pulse oximetry by home health on prn checks,
y Ideal O2 saturation range 82‐95%
y Check at rest and with feeds
y Pediatric Pulmonary follow up 4‐6 weeks post discharge
y RSV prophylaxis per AAP risk criteria
Hansell DM. Eur Respir J. 2001;17:1294‐313; Lynch DA, et al. Am J Roentgenol 1999;173:713‐8
Pediatric Management, BPD
y Pulse oximeter checks at each visit (82‐95%)
y Adjust diuretic therapy for weight gain
y Serum electrolytes q 2‐4 weeks while on diuretics, may need addition of NaCl or KCl feeding supplement
y Office visits for wheezing, aggressive treatment
y Majority of patients off oxygen and diuretic therapy within 6 mos of NICU discharge
y Nutrition, Nutrition, Nutrition
y May have need for increased caloric intake but with volume restriction. “dense” formula use (up to 30 cal.oz = 1 cal/ml)
Apnea and Monitoring
y NICHD Consensus group 2006
y “No consensus has been reached regarding the definition, diagnosis, or treatment of apnea of prematurity”
y Available technology is rarely used to document real time events
y The observational period after therapy is unknown
y There is an infrequent association between GER and apnea
y Definition:
y The cessation of breathing for more than 20 sec or apnea or the cessation of breathing for less than 20 sec if it is accompanied by bradycardia or oxygen desaturation
PEDIATRICS Vol. 117 No. 3 March 2006, pp. S47‐S51 (doi:10.1542/peds.2005‐0620H)
Mike Devoe, MD
Apnea Types
y Central Apnea: Cessation of airflow and effort
y Obstructive apnea: cessation of airflow, effort preserved
y Mixed
y Periodic Breathing: periods of irregular respiration for as long as 20 sec followed by apnea periods of 10 sec or less, at least 3 times in succession
y 2‐6% of time in healthy term newborns
y Up to 25 % of time in preterm infants
y Most commonly occurs in active sleep
y Pathophys:
y Prolonged brainstem conduction times in apnea patients
y Usually occurs in REM sleep
y Blunting of CO2 response in preterm infants
7/31/2010
Apnea management, post discharge
y Monitoring indicated for infants with persistent apnea despite medical therapy
y Indications for home monitoring:
y “clinically significant apnea” or ALTE
y Recording monitoring documenting apnea
y GER with apnea
y Sib of SIDS, per NIH consensus, only after 2 SIDS related deaths occur in a family
y NICU Monitoring done for:
y
Apnea episodes within 1 week of discharge, despite medication
y
GER with apnea within last week prior to discharge
y
NOT routinely used for patients being discharged on oxygen therapy with “stable” oxygen requirement prior to discharge
y
Obstructive airway anomaly, Pierre Robin, Trach patients, etc
y Incidence: up to 70 % of all preterms < 34 weeks
Apnea, out pt mgmt
y EDUCATION:
y Prenatal and postnatal Tobacco use
y Prone sleeping position
Apnea Monitoring
y Weaning:
y For patients discharged on medication and monitoring
y
No significant apnea for 1‐2 weeks
y Pacifier use
y Discontinue medication by 8 wks post discharge
y Soft Bedding
g
y Monitor additional 4 weeks
y “Co‐bedding”
y Discontinue monitor if no further significant apnea events
y Illnesses in infants with BPD
y Monitor Downloads
y
Valuable only if monitor is used
y
Performed monthly
y
Troubleshooting:
y Genetic Factors
y Duration of Monitoring:
y Usually minimum of 6 weeks
y Medication use:
y Maintain therapeutic dosing, 5 mg/kg
y
Levels not necessary
y
Don’t let patient “outgrow” the dose – either therapeutic or no dosing
y
y
y
Loose leads
Monitor alarms set too high, decrease low HR alarm to 60 by 4 months if still in use
Interference, artifact common
Mike Devoe, MD
7/31/2010
Hearing and vision difficulty
Vision/Hearing
y Retinopathy of Prematurity
y Oxidant injury to developing retinal vessels
y
Oxygen therapy, transfusions, iron therapy, nutrition?
y Vascular development not complete until 42‐44 weeks
Vascular development not complete until 42 44 weeks
y Protocol, y
NICU:
Beginning at about 42 days age, ROP check per Vanderbilt Ophthalmology
y Recheck every two weeks until vessels mature
y Laser surgery if progressions
y F/U at 6 mos with ped/general ophthlamology
Hearing Defecits
y Etiologies:
y Genetic (Conexin Gene)
y Hypoxic encephalopathy
T i (bili bi ibi i )
y Toxins (bilirubin, antibiotics, etc)
y Structural anomaly
y
Inner/outer ear
y Testing Protocols
y OAE vs ABR
y
If fail x2, TEIS referral, BAER, audiology, genetic screen
Mike Devoe, MD
7/31/2010
Nutrition:
Nutrition
y At risk groups as identified
y Use of growth curves for preterm infants, corrected for gestational age
y Use of preterm formulas for trace mineral, calcium, U f f
l f i
l l i
vitamin intake for all infants < 35 weeks gestation, continue through 6 mos post discharge
y Supplemental Vitamin use, polyvisol w,w/out iron
y Nutritional concerns:
y Failure to follow growth curves
y Assessment:
y Strict I/O, caloric estimates
l
y Type of intake
y Unusual outputs?
y Higher energy requirement
y
y
y
Post surgical
Respiratory exacerbations
Congestive cardiac disease
Nutrition Basics
y Neosure or Enfacare until 6‐9 months
y If excessive wt increase, verify no cereal addition to bottle, etc
y May also mix neosure to 20 cal/oz
If breastfeeding at least 2 neosure feeds/day
y If breastfeeding, at least 2 neosure
y No soy formula, low bioavailabililty of calcium and phosphours
y If feeding intolerance is documented, may switch to pregestimil, alimentum or nutramigen
y PolyViSol for all breast fed infants and all bottle fed infants until taking 1 liter of term formula/day
y Wait to introduce solids until infant is at least developmentally 4‐6 mos of age
Nutrition – problem solving 101
y Plot growth as age adjusted, if not following curve:
y Ensure adequate caloric intake
y
y
y
0‐4 mos – breast fed 10‐12 feeds/day, bottle 16‐24 oz; 24‐36 oz
4 6 mos breast fed 8‐10 feeds/day, bottle 26‐40 oz
4‐6 mos –
breast fed 8 10 feeds/day bottle 26 40 oz
6‐8 mos – breast fed 6‐8 feeds/day, bottle 24‐32 oz, ½ cup cereal, 3‐4 tbsp/day veggies, fruits, meats 1‐2 tbsp/day
y If intake is adequate on good intake of solids, can give avocados, vegetable oil, y Increase formula concentration to 24‐27 cal/oz
y R/O aspiration, stool loss
Periventricular Leukomalacia
Mike Devoe, MD
7/31/2010
IVH/PVL, local data
Developmental Outcome, things to watch for ETSU NICU Follow up
y Multidisciplinary
y Neonatology
y Peds certified physical therapy
D l
l h l
f i
y Developmental psychology for testing
y Audiology
y Speech/Language
y Perinatal Nutrition
y Others as needed
Pediatrics 2004; 113:594–
600; quality of life, Known Risk factors:
y
y
y
y
Very Low Birth weight
Asphyxia, (multisystem, acidosis)
BPD (oxygen @ 36 weeks)
Neurologic:
y Microcephaly, TORCH
y Neonatal Seizures
y Meningitis
y IVH
y PVL
y Psychosocial Issues: (substance abuse, abuse)
y Special Needs (monitors, oxygen, tracheotomy, g‐tube
Mike Devoe, MD
7/31/2010
F/U clinic
y Goal: provide a central location for appropriate evaluation and referral for neonates post NICU discharge
y Resource for primary care providers in the area
p
y
p
y Appropriate feedback to primary care
y No treatment is done in the clinic
y Diagnosis and referral only with appropriate agencies
y No primary care in clinic
y 1st visit at 2‐3 mos post discharge, then q 2‐6 mos, dependent on patient needs through age 2 yrs
F/U clinic, types of assessment
y Nutrition:
y Audiology
y Speech/language
y PT
y Developmental
Fig 2. Timeline: child outcomes
Summary
y Corrected Gestational Age: up through 9 mos
y Plot growth curves and developmental milestones
y Immunize based on chronological age, RSV y Screen for nutrition problems, especially patients with severe IUGR, BPD
y Assess tone abnormalities
y Use outside resources
y
Pediatrics 2004;114:1377‐1397
Care connection, TEIS, neonatal follow up clinic
y Watch for y Inguinal hernias
y Late onset hydrocephalus
y Intestinal stenosis post NEC
y Maintain medications appropriate for weight
y “Premie” formula for 6 mos post discharge
Copyright ©2004 American Academy of Pediatrics
Mike Devoe, MD
Summary
y Corrected gestational age: 9‐18 mos
y Plot growth and development
y Screen for tone and motor delay
y Reassess hearing status
y Screen for language milestones
y Ophthalmology evaluation, especially with history of BPD
y Immunizations, RSV and influenza per guidelines
7/31/2010