Neonatal Cold Injury Syndrome


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Neonatal Cold Injury Syndrome

  1. 1. Neonatal Cold Injury Syndrome (sclerema neonatorum)
  2. 2. Objectives What will I learn? Etiologies and pathophysiology Symptoms Diagnosis Treatment
  3. 3. Definition Neonatal Cold Injury Syndrome -- mainly caused by cold stress , --the clinical features are low body temperature and s cleredema , --serious one may appear multiple organ dysfunction.
  4. 4. Scleredema is a kind of disease characterized by hardening of the skin and subcutaneous tissue, often associated with subcutaneous edema.
  5. 5. Etiology and pathophysiology Charateristic of temperature regulation and subcutaneous fatty composition in newborn  immaturity of temperature regulation center  relative large surface area and rich blood flow cause poor thermal insulation
  6. 6.  limited storage of energy, heat production mainly by brown fatty metabolism, lacking shivery thermogenesis  more quantity of saturated fatty acid with higher melting point Imbalance between heat production and loss
  7. 7. Distribution of neonatal brown fat
  8. 8. Cold injury ● Cold environment increase heat loss, low body temperature cause constriction of peripheral blood vessels, dysfunction of microcirculation ● Low body temperature and cold environment cause anoxia , metabolic disturbance and acidosis even multiple organ dysfunction ( MOD )
  9. 9. Other Factors ● severe infection, ● premature, ● asphyxia, ICH, ● erythroblastosis
  10. 10. irregulation of temperature center relative larger surface cold 、 non-enough intake infection 、 asphyxia heat production of brown fat↓ anoxia, acidosis higher saturated fatty acid higher melt point body temperature ↓ coagulation of subcutaneous fat Pathogenesis of Neonatal Scleredema
  11. 11. Anoxia, acidosis coagulation of subcutaneous fat constriction of skin vessels anoxia of tissue hardening of skin Slowly blood flow disturbance of microcirculation capillary permeability ↑ edema circulating volume↓ shock multiple organ dysfunction DIC
  12. 12. Clinical Menifestation usually occur in cold season, during first 3 days or any time in preterm infants Low body temperature Scleredema
  13. 13. ● feature: skin and subcutaneous tissue become indurated, woody, non-pitting, cold to touch, involved area may with edema, redness, cyanosis; symmetrical ● Sequence: calves->thighs->low extremities->buttock->cheeks->upper extremities->whole body Scleredema
  14. 14. Neonatal scleredema
  15. 16. multiple organ dysfunction bradycardia, dyspnea, microcirculation disturbance, shock, DIC, acute renal failure, pulmonary hemorrhage
  16. 17. Evaluation of body surface area Head and neck 20% Upper limbs 18% Anterior part of trunk 14% Posterior part of trunk 14% Buttock 8% Lower limbs 26% 20% 9% 9% 14% 14% 8% 13% 13%
  17. 18. Degrees of NCIS Body temperature(℃) involved area change of organic anus T axil – anus T (% 、 color) function I 0 ≥ 35 positive < 20 no change (mild) pale II 0 < 35 0 or positive 20 ~ 50 poor reaction (moderate) dark red bradycardia III 0 < 35 negative > 50 shock 、 DIC 、 (severe) or < 30 cyanotic PH or ARF
  18. 19. Laboratory Examination nonspecific examination for diagnosis. eg. blood gas analysis, CT, PT, blood glucose level, platelet, electrolytes, BUN, fibrogen, etc. EKG, X - ray
  19. 20. Differential diagnosis <ul><li>Neonatal edema </li></ul><ul><li>Localized edema </li></ul><ul><li>Premature infant edema </li></ul><ul><li>--hypoalbuminemia, hyponatremia </li></ul><ul><li>Hemolytic disease of newborns </li></ul><ul><li>- anemia, splenohepatomegalia or Jaundice </li></ul><ul><li>√ Congenital nephrosis </li></ul><ul><li>-abnormal in urine </li></ul>
  20. 21. Neonatal edema
  21. 22. Differential diagnosis <ul><li>Subcutaneous gangrene </li></ul><ul><li>- staphylococcus aureus </li></ul><ul><li>-compressive site or impaired site </li></ul><ul><li>-swelling, blush, hard </li></ul><ul><li>-darkening, bleed, ulcer </li></ul><ul><li>-obscure boundary </li></ul>
  22. 23. Neonatal Subcutaneous Gangrene
  23. 24. Treatment  Restoration of body temperature  Energy supply and fluid infusion  Correction of organ dysfunction · correction of acidosis and volume expansion · treatment of pulmonary hemorrhage · arrangement of ARF and DIC  Others: antibiotics, symtomatic therapy
  24. 25. Treatment <ul><li>Rewarming </li></ul><ul><li>T R >30 ℃, TA-R≥0 </li></ul><ul><li>--Placed in a neutral thermal </li></ul><ul><li>environment </li></ul><ul><li>--Returned to normal temperature </li></ul><ul><li>during 6~12 hours </li></ul>
  25. 26. Treatment <ul><li>T R < 30 ℃, TA-R<0 </li></ul><ul><li>Placed in a incubator where environmental temperature higher 1~2 ℃ than body temperature( 0.5-1℃/h ) </li></ul><ul><li>Kept in a neutral thermal environment when T R ≥ 35 ℃ </li></ul><ul><li>Returned to normal temperature during 12~24 hours </li></ul>
  26. 27. Treatment Ways of rewarming --Incubator --Open radiant warmer bed --Others water bath, electric blanket , Kangaroo Care, etc
  27. 30. Open radiant warmer bed
  28. 33. kangaroo care
  29. 34. Prevention ¤ Neonatal care: warm environment temperature, enough clothes ¤ Encourage early breast feeding ¤ Prevent high risk factors: premature, infection, asphyxia
  30. 36. Conclusion and Review ¤ How to diagnose neonatal sepsis? ¤ Which marker can indicate neonatal infection? ¤ How many factors can cause NCIS? ¤ Which complication is caused by NCIS? ¤ State the clinic S/S and degrees of NCIS.
  31. 37. Thank You
  32. 38. Clinical case presentation
  33. 39. Clinical case presentation <ul><li>Patient1:10.09.06 </li></ul><ul><li>Sex: male </li></ul><ul><li>GA:32 +2 W </li></ul><ul><li>BW:1240g </li></ul><ul><li>Vaginal delivery Apgar:8-10-10 </li></ul><ul><li>pH:7.22 </li></ul>
  34. 40.  PROM of 2days intrapartum ampicillin because of PROM and maternal elevation of CRP  Admitted to NICU duo to prematurity  General condition is unstable
  35. 41. <ul><li>Frequent apnea 2 hrs after birth, </li></ul><ul><li>aminophyllin and CPAP was given for 3 days and apnea disappeared. </li></ul><ul><li>Because of VLBW, umbilical venous catheterization was performed on D 1 and the catheter was removed on D 7 . PICC was inserted on D 7 . </li></ul>
  36. 42. <ul><li>The general condition was stable after D 3 except poor enteral feeding. </li></ul><ul><li>On postnatal D 13 , he was getting worse : tachypnea, tychycardia, pale, grunting , abdominal distention, cyanosis, low BP and hypothemia. </li></ul><ul><li>-- antibiotics , IVIG, CPAP was given . </li></ul>
  37. 43. Questions <ul><li>What kinds of diseases did the baby suffer? </li></ul><ul><li>What kinds of Lab tests would you order? </li></ul><ul><li>How can you save his life? </li></ul><ul><li>How about his prognosis? </li></ul>
  38. 44. Septic work-up <ul><li>Complete Blood Count </li></ul><ul><li>Blood & Urine cultures </li></ul><ul><li>Lumbar Puncture </li></ul><ul><li>Chest X-Ray </li></ul><ul><li>Line cultures </li></ul>