What are the management strategies for newborns with conditions such as respiratory failure, Potter sequence, extreme prematurity, sepsis, and congenital heart disease?

Audit Preparation for Neonatal Deaths: Management Strategies

March: Respiratory Failure Secondary to PPHN from Neonatal Pneumonia

Inhaled nitric oxide (iNO) at 20 ppm is the first-line treatment for PPHN, with ECMO reserved for refractory cases with oxygenation index >25. 1

Initial Management

• Optimize lung recruitment before or concurrent with iNO initiation - lung recruitment strategies significantly improve iNO efficacy in PPHN with parenchymal lung disease like pneumonia 1, 2
• Start iNO at 20 ppm; doses up to 80 ppm show no additional benefit 3
• Metabolic alkalinization remains critical during initial resuscitation as PPHN can reverse when acidosis is corrected 1

Escalation Strategy

• ECMO is indicated when oxygenation index exceeds 25 despite iNO and optimized ventilation 1
• Consider sildenafil as adjunctive therapy for iNO-refractory PPHN with OI >25 1
• Inhaled prostacyclin analogs may be added for refractory cases with OI >25 1
• Milrinone is reasonable for PPHN with left ventricular dysfunction 1

Antibiotic Management

• Empiric antibiotics must be administered within 1 hour of sepsis identification 1
• Blood cultures before antibiotics when possible, but never delay administration 1

Pitfalls to Avoid

• Suboptimal lung inflation compromises iNO efficacy - ensure adequate recruitment 2
• Evaluate for alveolar capillary dysplasia or genetic surfactant diseases if severe PPHN fails to improve after vasodilator, lung recruitment, or ECMO therapy 1

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April: Potter Sequence (Pulmonary Hypoplasia, Bilateral Renal Agenesis, Anhydramnios)

Potter sequence with bilateral renal agenesis is universally fatal; management focuses on comfort care and family support rather than aggressive intervention.

Key Considerations

• Pulmonary hypoplasia from anhydramnios prevents adequate gas exchange
• Bilateral renal agenesis is incompatible with life
• Any newborn with shock and hepatomegaly or cyanosis should have prostaglandin infusion started until complex congenital heart disease is ruled out by echocardiography 1

Audit Focus

• Document prenatal diagnosis and counseling
• Review decision-making regarding resuscitation at delivery
• Ensure appropriate palliative care protocols were followed

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May: Extreme Prematurity (27 weeks, SGA) with Sepsis, DIC, and Pulmonary Hemorrhage

Aggressive fluid resuscitation with 20 mL/kg boluses up to 60 mL/kg in the first hour, followed by early inotropic support if fluid-refractory, is essential for septic shock in preterm neonates. 1

Sepsis Management

• Administer empiric antibiotics within 1 hour 1
• Push 20 mL/kg isotonic crystalloid or albumin boluses over 5-10 minutes, up to 60 mL/kg total 1
• Stop fluid resuscitation if hepatomegaly or rales develop - initiate inotropes instead 1
• Begin peripheral inotropic support immediately if fluid-refractory; obtain central access urgently 1

DIC and Pulmonary Hemorrhage

• Use plasma therapies to correct sepsis-induced thrombotic purpura disorders including progressive DIC 1
• Target hemoglobin 10 g/dL during resuscitation of low ScvO2 shock (<70%); after stabilization, target <7 g/dL is reasonable 1
• Platelet transfusion per adult guidelines 1
• Surfactant treatment for pulmonary hemorrhage is plausible as blood inhibits surfactant function, though evidence is limited to observational reports 1

Respiratory Support for Extreme Prematurity

• Start resuscitation with 21-30% oxygen, then titrate to target saturations 1
• Antenatal steroids reduce mortality (RR 0.62), RDS (RR 0.65), and surfactant use (RR 0.45) 1
• Consider early surfactant for RDS 1
• Use lung-protective ventilation strategies 1

Hemodynamic Monitoring

• Target normal MAP-CVP and ScvO2 >70% 1
• For cold shock with normal blood pressure: titrate dopamine or epinephrine centrally 1
• For warm shock: titrate norepinephrine centrally 1

Additional Critical Interventions

• Hydrocortisone for fluid-refractory, catecholamine-resistant shock with suspected absolute adrenal insufficiency 1
• Correct hypoglycemia and hypocalcemia immediately 1
• Control hyperglycemia to <180 mg/dL; glucose infusion must accompany insulin therapy in newborns 1
• Monitor drug toxicity labs - metabolism is reduced during severe sepsis 1

ECMO Consideration

• Consider ECMO for refractory pediatric septic shock and respiratory failure 1
• Expected survival with ECMO in neonatal sepsis is approximately 80% 1
• Limit ECMO flow to ≤110 mL/kg/min to avoid hemolysis 1

Fluid Overload Management

• Use diuretics when shock resolves; if unsuccessful, initiate CVVH or intermittent dialysis to prevent >10% total body weight fluid overload 1

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June: Congenital Heart Disease (Coarctation of Aorta, VSD) with Pulmonary Hypertension, Sepsis, Pneumonia, and Myocarditis

Any newborn with shock and hepatomegaly, cyanosis, cardiac murmur, or differential upper/lower extremity blood pressures must receive prostaglandin infusion immediately until complex congenital heart disease is excluded by echocardiography. 1

Cardiac-Specific Management

• Start prostaglandin E1 infusion for ductal-dependent lesions 1
• Evaluate for differential pulses and blood pressures (coarctation) 1
• Echocardiography to define anatomy and assess pulmonary hypertension severity 1

Pulmonary Hypertension Secondary to CHD

• Cardiac catheterization should include acute vasoreactivity testing unless contraindicated 1
• Positive AVT response: ≥20% decrease in PAP and PVR/SVR without decreased cardiac output 1
• Repeat catheterization within 3-12 months after therapy initiation or with clinical worsening 1

Sepsis/Pneumonia/Myocarditis Management

• Antibiotics within 1 hour 1
• Fluid resuscitation with extreme caution - stop if hepatomegaly or rales develop 1
• Early inotropic support for myocardial dysfunction 1
• Milrinone reasonable for low cardiac output with elevated SVR 1

Hemodynamic Strategy

• Vasodilator therapies plus inotropes for low cardiac output with elevated SVR and normal blood pressure 1
• Avoid excessive fluid administration in presence of cardiac dysfunction 1

Critical Pitfalls

• Distinguish cardiogenic shock from septic shock - management differs fundamentally 1
• Rule out inborn errors of metabolism causing hyperammonemia or hypoglycemia that simulate septic shock 1
• Monitor for PPHN causing right ventricular failure with right-to-left shunting and cyanosis 1

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Universal Audit Considerations Across All Cases

Documentation Requirements

• Time to antibiotic administration for sepsis cases 1
• Fluid volumes administered and hemodynamic response 1
• Oxygenation indices and response to therapies 1
• Timing of escalation to advanced therapies (iNO, ECMO) 1

Quality Metrics

• Adherence to 1-hour antibiotic window for sepsis 1
• Appropriate use of lung recruitment with iNO 1, 2
• Timely recognition of fluid overload and initiation of diuretics/CVVH 1
• Proper ECMO candidacy assessment and timing 1