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
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
● Localized edema
● Premature infant edema
-- hypoalbuminemia, hyponatremia
● Hemolytic disease of newborns
- anemia, splenohepatomegaly or Jaundice
● Congenital nephrosis
- abnormal in urine
- staphylococcus aureus
-compressive site or impaired site
-swelling, blush, hard
-darkening, bleed, ulcer
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
● T R >30 ℃, TA-R≥0
--Placed in a neutral thermal
--Returned to normal temperature
during 6~12 hours
● 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
Open radiant warmer bed
Huge omphalocele( 巨大脐膨出）
Prevention ● Neonatal care: warm environment, enough clothes ● Encourage early breast feeding ● Prevent high risk factors: premature, infection, asphyxia
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.
Mini case discussion
Clinical case presentation
GA:32 +2 W
Vaginal delivery Apgar:8-10-10
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 .
What kinds of diseases did the baby suffer? Predisposing factor?