1 / 34

NICU AUDIT

NICU AUDIT . e.y . P reterm via normal spontaneous delivery 2 9 year old G1P1 (0101) 32 6/7 weeks AOG, MT 34 AGA Apgar 8, 9 (H 90’s). BW 1930 g BL 44 cm HC 30 cm CC 27 1/2 cm AC 23 cm. Maternal history. 1 st Trimester – threatened abortion

yagil
Download Presentation

NICU AUDIT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. NICU AUDIT

  2. e.y. • Preterm via normal spontaneous delivery • 29 year old G1P1 (0101) • 32 6/7 weeks AOG, MT 34 AGA • Apgar 8, 9 (H 90’s) • BW 1930 g • BL 44 cm • HC 30 cm • CC 27 1/2 cm • AC 23 cm

  3. Maternal history • 1st Trimester – threatened abortion • Consult: Dihydrogesterone and Isoxuprine • 3rd Trimester- Upper respiratory tract infectiom • Consult: Cefuroxime

  4. Past Medical History: • (+) Bronchial asthma since childhood, no maintenance medications, last attack: 2010 • Ganglion cyst, left hand; s/p excision in 2000 • Family History: • Diabetes, Hypertension, Asthma • Personal/Social History • Unremarkable • OB History: • G1 – present pregnancy • Feeding history • Mixed feeding, expressed breastmilk+milk formula

  5. Physical findings • 1 cord coil • Flat fontanels • No molding, caput • Microtia, right ear • Hematoma, upper lip • No cleft lip or palate • (-) alar flaring • Good air entry, no retractions • HR 90bpm to 110bpm, Good cardiac activity, • Soft abdomen • Grossly male genitalia with descending testes • Full pulses

  6. DIAGNOSIS LIVE PRETERM BABY GIRL SEPSIS UNSPECIFIED MICROTIA, RIGHT EAR

  7. PLAN • Diagnostics: CBC PC, Blood culture and sensitivity, HGT • Therapeutics: • UV cannulation • D10W 100ml to run at 6.4mk/hr (TFR 80mg/kg/day) • Vitamin K 0.1mL/IM • Erythromycin eye ointment • Hepatitis B vaccine 0.5mL/IM • IV antibiotics: • Amikacin 34mg q36hrs (17.6 mg/kg/day) • Ampicillin 100mg q12hrs (103.6 mg/kg/day)

  8. HGT= 95mg/dl Abdominal X-ray (12/30): umbilical catheter directed superoposteriorly with its tip at the level of T10. Ileus.

  9. 9th hour of life

  10. Day 1 of life

  11. Blood culture: No growth in 7 days Abdominal X-ray (12/30): umbilical catheter directed superoposteriorly with its tip at the level of T10. Ileus.

  12. 33rd hour of life

  13. Going day 4 of life

  14. Going day 5 of life

  15. Going day 6 of life

  16. Blood culture: No growth in 7 days Abdominal X-ray (12/30): umbilical catheter directed superoposteriorly with its tip at the level of T10. Ileus.

  17. Going day 8 of life

  18. Blood culture: No growth in 7 days Abdominal X-ray (12/30): umbilical catheter directed superoposteriorly with its tip at the level of T10. Ileus.

  19. Going day 9 of life

  20. Blood culture: No growth in 7 days Abdominal X-ray (12/30): umbilical catheter directed superoposteriorly with its tip at the level of T10. Ileus.

  21. Working diagnosis • Live preterm baby boy, delivered via normal spontaneous delivery at 32 6/7 weeks AOG, MT 34 weeks, AGA, AS 8,9 • Sepsis unspecified • Hyperbilirubinemia unspecified • Microtia, right ear

  22. Microtia

  23. Microtia • a congenital anomaly of the ear that ranges in severity from mild structural abnormalities to complete absence of the ear • can occur as an isolated birth defect or as part of a spectrum of anomalies or a syndrome • often associated with hearing loss • hearing impairment and surgical ear reconstruction Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of Medical Genetics. 2012 January ; 158A(1): 124–139.

  24. Microtia: prevalence • prevalence varies among regions, from 0.83 to 17.4 per 10,000 births • considered to be higher in Hispanics, Asians, Native Americans • Males > Females: estimated 20-40% increased risk • Unilateral: 77–93% (right) Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of MedicalGenetics. 2012 January ; 158A(1): 124–139.

  25. Microtia: risk factors • low birth weight • higher maternal parity • maternal acute illness and use of medications (specific acute maternal conditions or medications were not identified in these studies) • maternal diabetes mellitus • Multiple births, advanced maternal age, low maternal education and Hispanic ethnicity • periconceptionalintake of folic-acid-containing supplements has been associated with reduced risk of microtia among non-obese women [Ma et al., 2010] Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of Medical Genetics. 2012 January ; 158A(1): 124–139.

  26. Microtia: risk factors reported in literature • General • Male sex all authors • First parity • High parity • Multiple births • Maternal acute illnesses • Maternal insulin dependent diabetes • Maternal use of medications • Advanced paternal age • Advanced maternal age • Low maternal education • Maternal exposure to altitude • Maternal residence in an urban area • Maternal residence in a rural area • Maternal exposure to air pollution • Race/Ethnicity • Native ethnicity Hispanic ethnicity Ecuadorian • Chilean • Asian, Philippine, Pacific Islander • Teratogens • Retinoic acid • Thalidomide • Alcohol • Mycophenolatemofetil Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of Medical Genetics. 2012 January ; 158A(1): 124–139.

  27. Microtia: classification system • Microtia, First Degree • Presence of all the normal ear components • median longitudinal length > 2 SD below the mean • Microtia, Second Degree • Median longitudinal length of the ear > 2 SD below the mean in the presence of some, but not all, parts of the normal ear • Microtia, Third Degree • Presence of some auricular structures, but none of these structures conforms to recognized ear components. • Anotia • Complete absence of the ear. Hunter A, Frias JL, Gillessen-Kaesbach G, Hughes H, Jones KL, Wilson L. Elements of morphology: standard terminology for the ear. Am J Med Genet A. 2009a; 149A(1):40–60.

  28. Microtia: associated anomalies • vertebral anomalies • macrostomia • oral clefts • facial asymmetry • renal abnormalities • cardiac defects • microphthalmia • holoprosencephaly, and polydactyly Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of Medical Genetics. 2012 January ; 158A(1): 124–139.

  29. Microtia: syndromes • Approximately 20-60%: have associated anomalies or an identifiable syndrome • Craniofacial microsomia • Townes-Brocks syndrome • Mandibulofacialdysostoses • Treacher-Collins • Nager syndrome • Oculo-auriculo-vertebral spectrum (OAVS): facial asymmetry, microtia, ear and facial tags, epibulbardermoids, microphthalmia, and macrostomia. [Heike and Hing,2009] • Craniofacial, or hemifacial, microsomia and Goldenharsyndrome • Extracranialfeatures include renal, cardiac and vertebral anomalies. • Most cases: sporadic, but may be genetic (autosomal>recessive) Luquetti, D., Heike, C., Hing, A. , Cunningham, M., Cox, T. Microtia: Epidemiology & Genetics. American Journal of Medical Genetics. 2012 January ; 158A(1): 124–139.

  30. Craniofacial microsomia • hemifacialmicrosomia, oculo-auriculo-vertebral spectrum, or first and second branchial arch syndrome • approximately 1 in 5500 live births • sporadically acquired association of anomalies: defect in the 1st and 2nd branchialarches (usually vascular insult) • 85-90% unilateral (right) • orbital distortion, mandibular hypoplasia • ear anomalies (microtia, accessory preauricular tags and/or pits, and middle ear defects with hearing impairment) • facial nerve involvement (hypoplasia of the facial muscles) • soft tissue deficiency, such as profound hypoplasia or absence of the parotid gland and masticatory muscles (temporalis, masseter) • Surgical correction: • Preauricular skin tags removed and correction of craniooralcomissure before 2yrs of age • Cranial remodeling at 8-12mos

  31. Townes-brocks syndrome • Autosomal dominant • Triad • Imperforate anus (82%) • Dysplastic ears (88%) (overfolded superior helices and preauricular tags)associated w/ sensorineural or conductive hearing impairment (65%) • Thumb malformations (89%) (triphalangeal thumbs, duplication, or rarely, thumb hypoplasia) • Renal impairment (27%), including ESRD may occur w/ or w/o structural abnormalities (malrotation, ectopia, renal hypoplasia, etc) • Congenital heart disease (25%) • Foot (52%) and genitourinary malformations (36%) • Management: Surgical, hemodialysis Kohlhase, J. 2012, May3. Townes-Brocks syndrome. Gene Reviews (extracted from www.ncbi.nlm.nih.gov/books/NBK1445)

  32. TREACHER COLLINS SYNDROME • mandibulofacialdysostosis • autosomal dominant disorder of craniofacial development • 1 in 25,000 to 50,000 live births • Clinical features: malar hypoplasia and a cleft in the zygoma, eyes with antimongoloid slant with colobomas (eyelid notch) along the lateral 1/3 of the lower lid; absent lashes from the medial two-thirds of the lower eyelid: face has a convex profile with a retrusive chin and jaw, associated with an overbite • External ear abnormalities • Profound conductive hearing loss: common in severe cases • left lip and palate and choanalatresia Dixon J, Trainor P, Dixon MJ. Treacher Collins syndrome. OrthodCraniofac Res 2007; 10:88.

  33. TREACHER COLLINS SYNDROME: Surgical management • can result in airway narrowing and respiratory compromise • with airway and feeding difficulties: first couple years of life • tongue-lip adhesion (glossopexy), distraction osteogenesis of the mandible, tracheostomy, correction of cleft lip and/or palate and choanal atresia, and gastrostomy tube placement • facial abnormalities: 7yrs-old • surgical correction of the mandible: at 13 to 16 year-old, as the jaw reaches dental and skeletal maturity

  34. Nager SYNDROME • Acrofacialdysostosissyndrome • rare disorder, sporadic> genetic • similar to Treacher-Collins but w/o eyelid colobomas • severe cleft palate (wide defect): always present • hypoplasia or agenesis of the radius and thumb • short stature • normal Intelligence; delays in speech and language development may occur secondary to hearing impairment • frequently have respiratory and feeding problems: may require gavage feeding or gastrostomy tube placement • High perinatal mortality rate (approximately 11%): related to respiratory compromise 

More Related