Simulation 08: Cyanotic Preterm Infant in Respiratory Distress

Size: px

Start display at page:

Download "Simulation 08: Cyanotic Preterm Infant in Respiratory Distress"

Priscilla Park
5 years ago
Views:

1 Flow Chart Simulation 08: Cyanotic Preterm Infant in Respiratory Distress Opening Scenario Section 1 Type: DM As staff therapist assigned to a Level 2 NICU in a 250 bed rural medical center you are called to the delivery room to assist in the respiratory management of a newborn infant Infant HR = 122/min; RR = 43/min and irregular; preductal SpO2 = 72%. Recommend oxygen therapy by mask Section 2 Type: IG Section 3 Type: IG Section 4 Type: DM Section 5 Type: DM Assess: Maternal Hx - 19 YO diabetic g3p0; infant 28 week/1200 g; Apgar 4/6; central cyanosis+retractions; no L/S results but no bubbles in foam shake test; no meconium observed SpO2=79% (35% O2); HR=128; RR=58/ breath sounds, cyanotic +grunting. After O2 to 40%, ph=7.31, PCO2=51, PO2=45. Recommend CXR, echo, hyperoxia test, pre-/post ductal SpO2. X-ray: reduced lung volume, reticulogranular appearance + air bronchograms; echo = mod L>R PDA; recommend surfactant replacement therapy Recommend INSURE (INtubation-SURfactant-Extubation) approach, followed by 4 to 6 cm H2O nasal CPAP End

2 Opening Scenario (Links to Section 1) Scenario Header (Briefly describe the setting, role and current situation): You are the staff therapist assigned to the Level 2 Special Care Nursery in a 250 bed rural medical center. You are called to the delivery room to assist in the respiratory management of a newborn infant. (Click the Start button below when ready to begin) 2

3 Decision-Making Section Simulation Section #: 1 Links from: Opening Scenario Links to Section #(s): 2 You arrive about 5 minutes after an uncomplicated vaginal birth. The male infant has been dried, is covered by a plastic membrane and is under a radiant warmer. His heart rate is 122/min. Respirations are about 43/min, interspersed with short (5-10 sec) periods of apnea. His SpO2 (right hand) is 72% on room air. Which of the following would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Link to Score Section Intubate and place on volume Physician disagrees. Make another -2 control A/C ventilation Initiate nitric oxide therapy (ino) Physician disagrees. Make another -2 Begin chest compressions and manual (bag-mask) ventilation Physician disagrees. Make another -1 Start oxygen therapy by mask Physician agrees Administer IV dexamethasone Physician disagrees. Make another -2 Perfect Score: 2 Minimum Pass Score: 2 3

4 Information-Gathering Section Simulation Section #: 2 Links from Section #: 1 Links to Section #(s): 3 Which of the following additional information would you obtain at this time? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section.) Requested Information: Data Score Maternal history Diabetic 19 year old Caucasian; gravida 3, +2 para 0; did not receive any prenatal care Foam shake test (pharyngeal Negative (no bubbles) +1 secretions) Capillary blood gas Physician disagrees -1 Gestational age and birth weight 28 weeks (estimated)/1200 g +2 General inspection/appearance Moderate central cyanosis, slight +2 intercostal retractions during inspiration Moro reflex Absent -1 Amniotic lecithin/sphyngomyelin Amniotic fluid not obtained +1 (L/S) ratio Apgar score 1 minute = 4; 5 minute = 6 +2 Ballard maturity assessment Not performed at this time -1 Presence of meconium None observed on baby or in pharynx +1 Perfect Score: 11 Minimum Pass Score: 8 4

5 Information-Gathering Simulation Section #: 3 Links from Section #: 2 Links to Section #(s): 4 After transfer to NICU, the infant is placed in an isolette on a cardiorespiratory monitor and an umbilical artery line is inserted. On 35% O2 his SpO2 (right hand) is 79%. Heart rate is 128/min, respirations are 58/min. After raising the FIO2 to 40%, which of the following additional diagnostic information would you obtain or recommend? (SELECT AS MANY as you consider indicated in this Section, then click on the Go To Next Section button below to proceed to the next Section.) Requested Information: Data Arterial blood gas ph = 7.31; PaCO2 = 51 torr; HCO3 = 25 mmol/l; BE = -1.0; PaO2 = 45 torr; SaO2 = 81% (40% O2) Chest transillumination Not performed -1 Echocardiogram Pending +2 Neonatal Behavioral Assessment Not performed -2 (Brazelton) Hyperoxia test PaO2 on 100% O2 = 138 torr +1 General inspection/appearance Central cyanosis and intercostal retractions persist, now accompanied by xiphoid retractions and expiratory grunting +2 Pre-/post-ductal SpO2s Pre = 81%; post = 81% (40% O2) +2 Breath sounds Diminished bilaterally +1 Chest X-ray Pending +2 Crying vital capacity Not performed -1 Perfect Score: 12 Minimum Pass Score: 10 Score +2 5

6 Decision-Making Section Simulation Section #: 4 Links from Section #: 3 Links to Section #(s): 5 The chest X-ray indicates reduced lung volume with diffuse reticulogranular appearance and air bronchograms. Echocardiogram indicates patent ductus arteriosus (PDA) with moderate systolic left-to-right shunting, no other structural defects noted. Which of the following would you recommend at this time? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Link to Score Section Intubation and pressure control SIMV Physician disagrees. Make another -2 Surfactant replacement therapy Physician agrees +2 5 Immediate surgery to correct the Physician disagrees. Make another -2 PDA Intubation and volume control A/C Physician disagrees. Make another -2 ventilation Nasal CPAP with 50% O2 Physician agrees Perfect Score: +2 Minimum Pass Score: 1 6

7 Decision-Making Section Simulation Section #: 5 Links from Section #: 4 Links to Section #(s): End The infant s physician decides to proceed with surfactant replacement therapy. Which of the following methods would you recommend for administration? (CHOOSE ONLY ONE unless you are directed to Make another ) Action/Recommendation Place infant in head-down position, administer surfactant via aerosol, then place on nasal CPAP Instill surfactant into pharynx, half dose each with infant in right and left lateral positions, then apply positive pressure via mask Intubate, instill surfactant through ET tube with infant in supine position, extubate to nasal CPAP Intubate, instill surfactant via bronchoalveolar lavage with infant in supine position, then place on CPAP Instill surfactant into pharynx with infant in Fowler s position, then intubate and place on pressure control ventilation Physician disagrees. Make another Physician disagrees. Make another Score -1-2 Link to Section Physician agrees. +2 End Physician agrees. +1 End Physician disagrees. Make another Perfect Score: 2 Minimum Pass Score: 1-2 7

8 RTBoardReview Simulation 08 Cyanotic Preterm Infant in Respiratory Distress Condition/Diagnosis: Neonatal Respiratory Distress Syndrome Simulation Scoring Individual Scoring (Used for All RTBoardReview Simulations) Score Meaning +2 Essential/optimum to identifying or resolving problem +1 Likely helpful in identifying or resolving problem 0 Neither helpful nor harmful in identifying or resolving problem -1 Unnecessary or potentially harmful in identifying or resolving problem -2 Wastes critical time in identifying problem or causes direct harm to patient -3 Results in life-threatening harm to patient Summary Scoring of Simulation 08 Section IG Max IG Min DM Max DM Min TOTALS MPL% 78% 66% Cut Score = IG Min + DM Min = = 22 MPL% = Minimum Pass Level as a percent = (Min/Max) x 100 IG and DM MPL% vary by problem; typically ranges are 77-81% for IG and 60-70% for DM If the IG or DM raw score is negative (e.g., -2) then the reported % score = 0 The Cut Score for a problem is the sum of IG Min + DM min To pass a problem, the sum of one s IG + DM raw scores must be the Cut Score 8

9 Take-Home Points RTBoardReview Simulation 08 Cyanotic Preterm Infant in Respiratory Distress Condition/Diagnosis: Neonatal Respiratory Distress Syndrome Assessment/Information Gathering Assess the history and look for evidence of prematurity (<37 weeks gestation), low birth weight (< 1500 g) and related maternal risk factors such as diabetes. Assess for lecithin/sphingomyelin (L/S) ratio (< 2) and absence of phosphatidyl glycerol as indicators of pulmonary immaturity. Observe for progressive respiratory distress shortly after birth, including tachypnea (> 60/min), subcostal and intercostal retractions, expiratory grunting, decreased breath sounds, nasal flaring, and cyanosis in room air (signs may not appear for a few hours). Recommend chest X-ray looking for low lung volume with diffuse reticulogranular ("ground-glass") appearance and air bronchograms. Recommend ABG, looking for respiratory acidosis with severe hypoxemia (P/F < 200). Differential Dx: meconium aspiration, pneumonia, congenital diaphragmatic hernia, cyanotic heart disease, persistent fetal circulation, transient tachypnea of the newborn. Recommend appropriate cultures to rule out an infection, e.g., pneumonia or sepsis. Recommend hyperoxia test and/or pre-/post-ductal SpO2 screening to rule out a critical congenital heart defect (CCHD) as the cause of the cyanosis and respiratory distress. Recommend an echocardiogram if extrapulmonary shunting is suspected, e.g. a PDA. Treatment/Decision-Making For women at risk of giving birth between weeks 24 to 34 of pregnancy, recommend corticosteroid administration prior to birth ("antenatal steroids" enhance lung maturation and reduces risk of RDS, brain hemorrhage and death). Maintain a neutral thermal environment via incubator or radiant warmer. Provide sufficient O2 to maintain a PaO2 between torr or SpO2 between 85-92%. For spontaneously breathing infants with clinical findings indicating RDS, implement early prophylactic surfactant therapy using the INSURE ("INtubation-SURfactant- Extubation ) approach, i.e., brief intubation after birth, surfactant administration, then immediate extubation to 4 to 6 cm H2O nasal CPAP or high flow cannula at 1-6 L/min. Recommend intubation and mechanical ventilation for any infant 27 gestational age whose mother did not receive antenatal steroids or if the infant: o is apneic or o is unable to maintain an adequate airway or o exhibits increased work of breathing (grunting, retractions, flaring) on CPAP or o cannot maintain a ph > 7.25 on CPAP To avoid volutrauma during mechanical ventilation, apply volume-controlled or volumetargeted ventilation with low tidal volumes (4-5 ml/kg) and let the PaCO2 rise as long as the ph remains > 7.20, i.e., permissive hypercapnia 9

10 Aim for early extubation to nasal CPAP when: o The infant exhibits adequate respiratory drive o Mean airway pressure are 7 cm H2O o Satisfactory oxygenation can be maintained on 35% O2 Do not recommend high-frequency ventilation (no benefit over conventional ventilation). Do not recommend inhaled nitric oxide (INO) therapy unless the IRDS is accompanied by PPHN. Follow-up Resources Standard Text Resources: Des Jardins, T, & Burton, GG. (2011). Respiratory Distress Syndrome. (Chapter 34). In Clinical Manifestations and Assessment of Respiratory Disease, 6th Ed. Maryland Heights, MO: Mosby- Elsevier. Useful Web Links: American Association for Respiratory Care. (2013). Clinical Practice Guideline. Surfactant Replacement Therapy. Respir Care, 58, Brown, MK & DiBlasi, RM. (2011). Mechanical ventilation of the premature neonate. Respir Care, 56, Centers for Disease Control and Prevention. (2103). Screening for Critical Congenital Heart Defects. European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants 2013 Update. (2013). Neonatology, 103, onat2013.pdf Hermansen, CL, Lorah, KN. (2007). Respiratory Distress in the Newborn. Am Fam Physician. 76, Pramanik, AK. (2012). Respiratory Distress Syndrome. Medscape/E-Medicine. Available at: Wheeler, KI, et al. (2011). Volume-targeted versus pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Neonatology, 100,

Simulation 3: Post-term Baby in Labor and Delivery

Simulation 3: Post-term Baby in Labor and Delivery Opening Scenario (Links to Section 1) You are an evening-shift respiratory therapist in a large hospital with a level III neonatal unit. You are paged