MECONIUM ASPIRATION SYNDROME TREATMENT
Category: Child Health
Abstract : Meconium Aspiration Syndrome Medical Care: • Prevention o Prevention is paramount. o Obstetricians should monitor fetal status in an attempt to prevent and assuage fetal stress. o When meconium is detected, administering amnioinfusion with warm sterile saline may be beneficial. This procedure dilutes meconium in the amniotic fluid; therefore, the severity of aspiration may be mi
Meconium Aspiration Syndrome Medical Care:
• Prevention
o Prevention is paramount.
o Obstetricians should monitor fetal status in an attempt to prevent and assuage fetal stress.
o When meconium is detected, administering amnioinfusion with warm sterile saline may be beneficial. This procedure dilutes meconium in the amniotic fluid; therefore, the severity of aspiration may be minimized.
o Upon delivery of the head of the baby, careful suctioning of the posterior pharynx decreases the potential for aspiration of meconium. When aspiration occurs, intubation and immediate suctioning of the airway can remove much of the aspirated meconium.
o No clinical trials justify suctioning based on the consistency of meconium.
Do not perform the following harmful techniques to prevent aspiration of meconium-stained amniotic fluid:
�� Squeezing the chest of the baby
�� Inserting a finger into the mouth of the baby
�� Externally occluding the airway of the baby
o The American Academy of Pediatrics Neonatal Resuscitation Program Steering Committee has promulgated the following guidelines for management of the baby exposed to meconium:
�� If the baby is not vigorous (Apgar 1-3): Suction the trachea soon after delivery (ie, before many respirations have occurred). Suction for no longer than 5 seconds. If no meconium is retrieved, do not repeat intubation and suction. If meconium is retrieved and no bradycardia is present, reintubate and suction. If the heart rate is low, administer positive pressure ventilation and consider suctioning again later.
�� If the baby is vigorous (Apgar >5): Clear secretions and meconium from the mouth and nose with a bulb syringe or a large-bore suction catheter. In either case, the remainder of the initial resuscitation steps should ensue: dry, stimulate, reposition, and administer oxygen as necessary.
• Intervention
o Maintain an optimal thermal environment and minimal handling because these infants are agitated easily and quickly become hypoxemic and acidotic.
o Continue respiratory care. Oxygen therapy via hood or positive pressure is crucial in maintaining adequate arterial oxygenation. If mechanical ventilation is required, make concerted efforts to minimize the mean airway pressure and to use as short an inspiratory time as possible. Use of surfactant has not yet been proven to be efficacious in this setting and is under investigation.
o Although conventional ventilation commonly is used initially, oscillatory, high-frequency, and jet ventilation are alternative effective therapies. Hyperventilation to induce hypocapnia and respiratory alkalosis is used as primary therapy for pulmonary hypertension. Inhaled nitric oxide has displaced the use of most intravenous pulmonary vasodilators.
o Pay careful attention to systemic blood volume and BP. Volume expansion, transfusion therapy, and systemic vasopressors are critical in maintaining systemic BP greater than pulmonary BP, thereby decreasing the right-to-left shunt through the patent ductus arteriosus.
o Extracorporeal membrane oxygenation (ECMO) is employed if all other therapeutic options have been exhausted.
Surgical Care:
Although primary management of air block syndromes is achieved by thoracic drainage tubes inserted by a neonatologist, a pediatric surgical consultation may be necessary in severe cases.
Consultations:
A pediatric cardiology evaluation is necessary to perform an echocardiogram. This imaging technique ensures normal cardiac structure and assesses the severity of pulmonary hypertension and right-to-left shunting. A pediatric neurology evaluation is essential in the presence of neonatal encephalopathy or seizure activity.
Diet:
• Perinatal distress and severe respiratory distress preclude feeding.
• Intravenous fluid therapy begins with adequate dextrose infusion to prevent hypoglycemia.
• Progressively add electrolytes, protein, lipids, and vitamins to ensure adequate nutrition and prevent essential amino acid and essential fatty acid deficiencies.
MEDICATION
In addition to the treatments listed below, surfactant replacement therapy is prescribed frequently. Natural bovine lung extract is administered to replace the surfactant that has been stripped. Surfactant also acts as a detergent to break up residual meconium, thereby decreasing the severity of lung disease. Although 4 different commercial surfactant preparations are available, the FDA has not yet approved surfactant for this indication. However, surfactant commonly is used in patients with MAS, even though its efficacy, dosage regimen, and most effective product still are not established clinically.
Drug Category: Pulmonary vasodilating agents -- Decreases pulmonary vascular resistance. Administer directly into the main pulmonary artery because the major complication is systemic hypotension without significant effects on pulmonary hypertension. Because of the severe systemic hypotensive effects of tolazoline and nitroprusside, inhaled nitric oxide is used more commonly.
Drug Category: Respiratory gases -- Inhaled nitric oxide (NO) has the direct effect of pulmonary vasodilatation without the adverse effect of systemic hypotension. Approved for use if concomitant hypoxemic respiratory failure occurs.
Drug Category: Systemic vasoconstrictors -- Used to prevent right-to-left shunting by raising systemic pressure above pulmonary pressure. Systemic vasoconstrictors include dopamine, dobutamine, and epinephrine. Dopamine is the most commonly used.
Drug Category: Sedatives -- Maximizes efficiency of mechanical ventilation and minimizes oxygen consumption.
Drug Category: Neuromuscular blocking agents -- Used for skeletal muscle paralysis to maximize ventilation by improving oxygenation and ventilation. Also used to reduce barotrauma and minimize oxygen consumption.
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