Neonatal cold injury syndrome
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Neonatal cold injury syndrome

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Neonatal cold injury syndrome Neonatal cold injury syndrome Presentation Transcript

  • Neonatal Cold Injury Syndrome (sclerema neonatorum)
  • Objectives What will I learn? Etiologies and pathophysiology Symptoms Diagnosis Treatment
  • Definition -- mainly caused by cold stress --the clinical features are low body temperature and scleredema --serious one may appear multiple organ dysfunction. Scleredema --- hardening of the skin and subcutaneous tissue
  • Etiology and pathophysiology Characteristics 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
  • ● 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
  • Distribution of neonatal brown fat
  • Cold injury ● Cold environment increase heat loss, low body temperature causes 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 )
  • Other Factors ● severe infection, ● premature, ● asphyxia, ICH, ● erythroblastosis
  • Imbalance between heat production and loss Heat production Non-enough intake √ √ √ cold √ asphyxia infection
  • Imbalance between heat production and loss Heat loss cold √ relative larger surface √ cold √ immature of temperature center
  • immature 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
  • 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 organs dysfunction DIC
  • ● usually occur in cold season ● during first 3 days or any time in preterm infants ● Low body temperature ● Scleredema ● MOD in severe case Clinical Manifestations
  • ● 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
  • Neonatal scleredema
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  • multiple organ dysfunction ● bradycardia, dyspnea, ● microcirculation disturbance, ● shock, DIC , ● acute renal failure, ● pulmonary hemorrhage
  • 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%
  • 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
  • nonspecific examination for diagnosis. blood gas analysis, CT, PT, blood glucose level, platelet, electrolytes, BUN, fibrogen, etc. EKG, X - ray Laboratory Examination
  • Differential diagnosis
    • Neonatal edema
    • ● Localized edema
    • ● Premature infant edema
    • -- hypoalbuminemia, hyponatremia
    • ● Hemolytic disease of newborns
    • - anemia, splenohepatomegaly or Jaundice
    • ● Congenital nephrosis
    • - abnormal in urine
  • Neonatal edema
  • Differential diagnosis
    • Subcutaneous gangrene
    • - staphylococcus aureus
    • -compressive site or impaired site
    • -swelling, blush, hard
    • -darkening, bleed, ulcer
    • -obscure boundary
  • Neonatal Subcutaneous Gangrene
  • treatment Heat loss Heat production Correction of organ dysfunction normal body temperature organs function
  • 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
  • Treatment
    • Rewarming
    • ● T R >30 ℃, TA-R≥0
    • --Placed in a neutral thermal
    • environment
    • --Returned to normal temperature
    • during 6~12 hours
  • Treatment
    • ● T R < 30 ℃, TA-R<0
    • Placed in a incubator where environmental temperature higher 1~2 ℃ than body temperature( 0.5-1℃/h )
    • Kept in a neutral thermal environment when T R ≥ 35 ℃
    • Returned to normal temperature during 12~24 hours
  • Treatment Ways of re-warming ● Incubator ● Open radiant warmer bed ● Others water bath, electric blanket , Kangaroo Care, etc
  • Incubator
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  • Open radiant warmer bed
  • Huge omphalocele( 巨大脐膨出)
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  • kangaroo care
  • Prevention ● Neonatal care: warm environment, enough clothes ● Encourage early breast feeding ● Prevent high risk factors: premature, infection, asphyxia
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  • 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.
  • Thank You
  • Mini case discussion
  • Clinical case presentation
    • Patient1:10.09.06
    • Sex: male
    • GA:32 +2 W
    • BW:1240g
    • Vaginal delivery Apgar:8-10-10
    • Umbilical pH:7.22
  •  PROM of 2days intrapartum ampicillin because of PROM( pre-rupture of membrane ) and maternal elevation of CRP  Admitted to NICU duo to prematurity  General condition is unstable
    • Frequent apnea 2 hrs after birth,
    • aminophyllin and CPAP ( continuous positive airway pressure ) was given for 3 days and apnea disappeared.
    • Because of VLBW, umbilical venous catheterization was performed on D 1 and the catheter was removed on D 7 . PICC ( peri-intravenous central-line catheterization ) was inserted on D 7 .
    • The general condition was stable after D 3 except poor enteral feeding.
    • On postnatal D 13 , he was getting worse : tachypnea, tachycardia, pale, grunting , abdominal distention, cyanosis, low BP and hypothemia.
    • -- antibiotics , IVIG, CPAP was given .
  • 05/26/10
  • Questions
    • What kinds of diseases did the baby suffer? Predisposing factor?
    • What kinds of Lab tests would you order?
    • How can you save his life?
    • How about his prognosis?
  • Septic work-ups
    • Complete Blood Count
    • Blood & Urine cultures
    • Lumbar Puncture
    • Chest X-Ray
    • Line cultures
  •