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CASE DISCUSSION

CASE DISCUSSION. Ontok , Abdul-Aziz Pelayo , May Angela Rodriguez, Melissa Samson, Edgardo Manzano , Luis Jocelyn, Eds. HISTORY. Identifying Data. Baby Boy J.C. Full Term, 37 weeks by P.A. 2600 g, appropriate for G.A. Cephalic presentation Repeat low-segment C.S.

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CASE DISCUSSION

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  1. CASE DISCUSSION Ontok, Abdul-Aziz Pelayo, May Angela Rodriguez, Melissa Samson, Edgardo Manzano, Luis Jocelyn, Eds

  2. HISTORY

  3. Identifying Data • Baby Boy J.C. • Full Term, 37 weeks by P.A. • 2600 g, appropriate for G.A. • Cephalic presentation • Repeat low-segment C.S. • 23 year old, G2P2

  4. Maternal Obstetrical History • OB Index: G2P2 (2002) • Previous Pregnancy: Date: 2007 Sex: Male BW: 2.7 kg Place: Perpetual Help Hospital Delivery Type: 1o Low-segment C.S. AOG: Full Term Complications: CephalopelvicDisroportion

  5. Antenatal History • LMP: September 04, 2008 • Prenatal Checkups: 2 at PGH • Medications Taken: None • Illnesses/Infection: None • Alcohol/Tobacco Use: None

  6. Labor • Onset of Uterine Activity: Spontaneous • Intensity of Contractions: Moderate • Membrane Status: Intact • Analgesia: None

  7. Delivery • Mode: Abdominal • Amniotic Fluid: Slightly Meconium Stained • Analgesia: Subarachnoid Block

  8. Immediate Neonatal Period • APGAR Score: 5, 9 • Resuscitation: • Supplementary O2 10 LPM via hood • Positive Pressure-Ventilation

  9. Family History • (-) Hypertension • (-) Diabetes Mellitus • (-) Bronchial Asthma • (-) Blood Dyscrasias

  10. PHYSICAL EXAMINATION

  11. PHYSICAL EXAM • GENERAL APPEARANCE: vigorously crying with active motor activity • VITAL SIGNS: T: 36.6oC HR: 130 bpm RR: 50 cpm Wt: 2600 g Lt: 49 cm HC: 32.5 cm CC: 31 cm AC: 28 cm

  12. PHYSICAL EXAM • SKIN: acrocyanotic, (-) lesions, (+) cracking, rare veins • HEAD: (-) molding, (-) cephalhematoma, both fontanels flat and soft, (-) overlapping sutures, BT: 8cm, BP: 9cm, SOB: 9cm, OF: 10.5cm, OM: 11.5cm • EYES: (-) discharges, anicteric sclerae, both pupils equally reactive to light

  13. PHYSICAL EXAM • EARS: (-) low-set ears, formed, firm with instant recoil • MOUTH: (-) circumoral cyanosis, (-) cleft lip, formed tongue, (-) cleft palate • CHEST/LUNGS: barrel-shaped, (+) subcostal & intercostal retractions, raised areola with 3-4 mm bud, (+) grunting, (-) tachypnea

  14. PHYSICAL EXAM • HEART: adynamic precordium, (-) thrills, normal rate, regular rhythm, (-) murmur • ABDOMEN: globular but not distended, nonpalpable liver • UMBILICUS: translucent, (-) meconium stained, 2 arteries & 1 vein • BACK: lanugo with bald areas, (-) dimpling, straight spine

  15. PHYSICAL EXAM • GENITALIA: both testes descended, scrotum with good rugae • ANUS: patent, (+) passage of meconium • EXTREMITIES: (-) polydactyly, (-) hip dislocation, plantar crease over anterior 2/3, equally strong & palpable pulses • NEUROLOGIC EXAM: (+) moro reflex, (+) sucking reflex, (+) grasping reflex

  16. PRIMARY IMPRESSION

  17. Primary Impression • MeconiumPneumonitis • Full term 37 weeks by PA 2600 grams AGA cephalic presentation delivered by repeat LSCS, AS 9,9 • Hyperbilirubinemia w/o set-up • r/o Nosocomial sepsis

  18. MECONIUM PNEUMONITIS • (+) history of meconium staining • baby received non-vigorous, HR 60s, poor muscle tone, with no response • (+) tachypnea • (+) grunting • (+) retractions

  19. DIFFERENTIAL DIAGNOSIS

  20. 1. Hyaline Membrane Disease • CONSIDERATIONS: • (+) tachypnea • (+) grunting • (+) retractions • RULED-OUT: • rare in term neonates • mother not GDM • worsens / peaks at 48-36 hours • CXR findings:ground glass appearance, air bronchogram, diffuse reticulogranular infiltrates

  21. 2. Transient Tachypnea of the NB • CONSIDERATIONS: • usually follows an uneventful normal FT SVD or cesarean section • early onset tachypnea with or without retractions • (+) grunting • RULED-OUT: • cyanosis relieved by minimal 02 • with rapid recovery in 3 days • lungs clear w/o rales or rhonchi • CXR: prominent pulmonary vascular markings (Sunburst pattern), overaeration, flat diaphragm • benign, self-limited course

  22. 3. Neonatal Pneumonia • CONSIDERATIONS: • (+) tachypnea • (+) grunting • (+) retractions • (+) cyanosis • RULED-OUT: • pre-natal history suggests infection • usually predisposed by pre-mature labor, PROM, increased IE • CBC usually: neutropenia, leukocytosis • cannot be fully ruled-out

  23. COURSE IN THE WARD

  24. On Admission • Born at PGH Nursery on May 7, 2009 with APGAR score 5, 9 • Started on Piperacillin-Tazobactam (75mkd) 195 mg IV q12 • Started on Amikacin (15mkd) 40 mg IV OD

  25. On Admission • Ordered CBC with PC, Blood typing, ABG, Na, K, Cl, Ca, CXR APL, Blood Culture and Sensitivity • Venoclysis started with D10W (80) @ 9cc/hr • NPO, Hgt q8 • O2 support at 10 lpm/hood

  26. On Admission Respiratory Acidosis ARTERIAL BLOOD GAS

  27. On Admission • Admitted at NICU 3 on May 7, 2009 • Received with fair pulses BP 30-40/20’s • Given total of 50 cc/kg PNSS IV bolus, BP improved to 40-50/30’s but still with fair pulses • Started on Dopamine @ 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc) • UVC inserted

  28. On Admission • Due to persistent desaturation (O2sats 80’s), patient intubated with MV settings 100%, 18/3, RR 60 LT 0.4 • O2sats improved to 98-100% • ABGs ordered • D10W increased to run for 10 cc/hour • STAT NaHCO3 5 meqs given • ABGs ordered

  29. On Admission ARTERIAL BLOOD GAS after intubation

  30. On Admission ARTERIAL BLOOD GAS after NaHCO3

  31. 1st HD, 1st DOL • PWI: FT 37 weeks PA, 2600g, AGA, ceph, repeat LSCS, LBB, AS 5,9; Neonatal Pneumonia vs MAS; PPHN precaution r/o sepsis • MV settings maintained • IVF shifted to D10IMB Ca 300 @ 10cc/hr

  32. 1st HD, 1st DOL CBC AND BLOOD TYPE

  33. 1st HD, 1st DOL ARTERIAL BLOOD GAS

  34. 1st HD, 1st DOL • Decrease RR to 50 then decrease by 2 q2 until 30 • Decrease FiO2 by 5 q2 until 60%

  35. 2nd HD, 2nd DOL • MV setting at 80%, 18/3, 44, 0.4 • ABGs ordered • Once FiO2 60%, may start feeding with 5cc EBM q3/OGT with SAP

  36. 2nd HD, 2nd DOL ELECTROLYTES

  37. 2nd HD, 2nd DOL • Start feeding 5cc EBM as ordered, if tolerated 3x, start increments: increase 5cc every feeding until 30cc • MV setting: 60% 18/5 26 0.4 • Wean FiO2 by 5 q2 til 21% • Wean RR by 2 q2 til 10 • Extract ABGs at RR=10

  38. 3rd HD, 3rd DOL • Prepare for extubation • Prepare O2 hood FiO2 30% • MV settings at 21%, 18/3, 14, 0.4 • Revise inotropes: Dopamine 0.5cc + D5W 23.5 cc to run at 1cc/hour then consume then discontinue

  39. 3rd HD, 3rd DOL • S/P Extubation • Placed on O2 hood FiO2 30% • Racemic epinephrine nebulization started to continue 2 more doses 15 minutes apart

  40. 3rd HD, 3rd DOL • Patient noted to be jaundiced up to thighs • For TB DB IB • Increase feeding to 35cc q3/OGT

  41. 3rd HD, 3rd DOL • For CPT with proper shields • Dopamine discontinued • NCPAP 30% PEEP 5 • ABGs • Noted vomiting with feeding; abdomen soft but distended • Feeding decreased to 30cc

  42. 3rd HD, 3rd DOL ARTERIAL BLOOD GAS

  43. 4th HD, 4th DOL • Increased feeding to 35cc • TB DB IB noted • Maintained on phototherapy • PWI: FT 37 wks by PA, 2600 g, AGA, cephalic, delivered via primary LSCS, LBG, AS 5,9; Neonatal pneumonia; Hyperbilirubinemia no set-up

  44. 4th HD, 4th DOL TOTAL BILI., DIRECT BILI., INDIRECT BILIRUBIN

  45. 4th HD, 4th DOL • 13cc of feeding residual noted; no abdominal distention • Feeding deferred • Wean FiO2 by 5 q2 until 21% • Coffee-ground noted

  46. 4th HD, 4th DOL • NPO • Start Famotidine 1mg IV q12 • Give Vit K 2mg slow IV push • ABGs ordered at 25% PEEP 5

  47. 4th HD, 4th DOL ARTERIAL BLOOD GAS

  48. 5th HD, 5th DOL • PWI: FT, 37 wks by PA, 2600g, AGA, cephalic, rpt LSCS, LBG, AS 5,9; neonatal pneumonia; hyperbilirubinemia with no set-up; rule out nosocomial sepsis • Still with jaundice and coffee ground material

  49. 5th HD, 5th DOL • For repeat CBC with PC, blood CS, eletrolytes • To start Ceftazidime (50mkd) 130mg IV q12h • NPO • IVF revised to: D10 1MB Ca 400 @ 13cc/hr • Please put patient on right side up

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