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Evidence ofhypothyroidism (see chap. 3). D. Prediction of hyperbilirubinemia that may require treatment in otherwise healthy infants >35 weeks' gestation 1. Visual inspection is not a reliable measure of serum bilirubin level. 2. A screening total serum bilirubin (tsb) collected predischarge from the newborn nursery at the time of the metabolic screen and plotted on an hourspecific bilirubin nomogram (fig. 26.3) is helpful in identifying infants at increased risk for developing hyperbilirubinemia that requires treatment. 3. Alternatively, transcutaneous bilirubin (tcb) measurement using multiple wavelength analysis (versus two-wavelength method) can reliably estimate serum bilirubin levels independent of skin pigmentation, postnatal age, and weight ofinfant. Similar to tsb, t cb can be used as a screening tool to identify infants at high risk for severe hyperbilirubinemia by plotting obtained values on an hour-specific bilirubin nomogram. Despite advancements in transcutaneous technology, extrapolation to serum bilirubin levels from t cb should continue to be done with caution.

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2. Resistance is the impediment to airflow due to friction between gas and airways (airway resistance) and between tissues of the lungs and chest wall (viscous tissue resistance). Almost half of airway resistance is in the upper airways, including the endotracheal tube when in use. Resistance is high in diseases characterized by airway obstruction, such as meconium aspiration and bpd. Resistance can change rapidly if, for example, secretions partially occlude the endotracheal tube. 3. Tidl.E constant is the product of compliance and resistance. This is a measure of the time it takes to equilibrate pressure between the proximal airway and the alveoli. Expiratory time constants are somewhat longer than inspiratory ones. When time constants are long, as in meconium aspiration, care must be taken to set ventilator inspiratory times and rates that permit adequate inspiration to deliver the required vr and adequate expiration to avoid inadvertent peep. 4. Functional residual capacity (frc) is a measure of the volume of the lungs at end expiration. Frc is decreased in diseases that permit alveolar collapse, particularly surfactant deficiency. 5. V/qmatching. Diseases that reduce alveolar surface area (through atelectasis, inflammatory exudates, or obstruction) permit intrapulmonary shunting of desaturated blood. The opposite occurs in persistent pulmonary hypertension when extrapulmonary shunting diverts blood flow away from the ventilated lung. Both mechanisms result in systemic recirculation of desaturated blood. 6. Work of breathing is especially important in the smallest infants and those with chronic lung disease whose high airway resistance, decreased lung compliance, compliant chest wall, and weak musculature may overwhelm their metabolic energy requirements and impede growth. C. Specific disease states. Several of the more common neonatal disease processes are desaibed in the subsequent text and are presented in table 29.3, along with the optimal ventilatory strategies. Before initiating ventilatory support, clinicians must evaluate for mechanical causes of distress, including pneumothorax or airway obstruction. 1. Rds (see chap. 33) a.

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Hemorrhagic infarctions are frequent complications of sinovenous female viagra for sale uk thrombosis. 5. The majority of cases of neonatal sinovenous thrombosis are associated with maternal conditions (including preeclampsia, diabetes, and chorioamnionitis) and/or acute systemic illness in the neonate. 6. Inherited thrombophilias have been reported in 15% to 20% of neonates with sinovenous thrombosis. 7. Ultrasound and ct scan can detect sinovenous thrombosis and associated complications, but mri with venography is the imaging modality of choice for the best detection of sinovenous thrombosis and cerebral injury. 8. Data on management is limited. In general, neonates with csvf without associated hemorrhage can be considered for anticoagulation therapy. If significant hemorrhage is present, anticoagulation should be reserved for cases in which thrombus is noted to propagate.

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Other diagnoses that should be considered in the infant presenting beyond the first few hours of life with a sepsis-like picture include bowel obstruction, necrotizing enterocolitis (nec), and inborn errors of metabolism. E. Evaluation of the symptomatic infant for eos. Laboratory evaluation of the symptomatic infant suspected of eos includes at minimum a complete blood count (cbc) with differential and blood culture. Other laboratory abnormalities can include hyperglycemia and metabolic acidosis. Thrombocytopenia as well as evidence of dic (elevated prothrombin time [pt], partial thromboplastin time [ptt], and international normalized ratio [inr]. Decreased fibrinogen) can be found in more severely ill infants. For infants with a strong clinical suspicion of sepsis, alp for cerebrospinalftuid (csf) cell count, protein and glucose concentration, gram stain, and culture should be performed before the administration of antibiotics if the infant is clinically stable. The lp may be deferred until after the institution of antibiotic therapy if the infant is clinically unstable, or if later culture results or clinical course demonstrate that sepsis was present. Infants with respiratory symptoms should have a chest radiograph as well as other indicated evaluation such as arterial blood gas measurement. Radiographic abnormalities caused by retained fetal lung fluid or atelectasis usually resolve within 48 hours. Neonatal pneumonia will present with persistent focal or diffuse radiographic abnormalities and variable degrees of respiratory distress. Neonatal pneumonia (particularly that caused by gbs) can be accompanied by primary or secondary surfactant deficiency. F. Treatment of eos. Empiric antibiotic therapy includes a broad coverage for organisms known to cause eos, usually a ~-lactam antibiotic and an aminoglycoside. In our institutions, we use ampicillin and gentamicin as initial therapy. We add a third-generation cephalosporin (cefotaxime or ceftazidime) to the empiric treatment of critically ill infants for whom there is a strong clinical suspicion for sepsis to optimize therapy for ampicillin-resistant, enteric gram-negative organisms, primarily ampicillin-resistant escherichia coli. (see table 49.1 for treatment recommendations.) supporti-ve treatments for sepsis include the use of mechanical ventilation, exogenous surfactant therapy for pneumonia and respiratory distress syndrome (rds), volume and pressor support for hypotension and poor perfusion, sodium bicarbonate for metabolic acidosis, and anticonvulsants for seizures. Echocardiography may be of benefit in the severely ill, cyanotic infant to determine if significant pulmonary hypertension or cardiac failure is present.