NICU Case Discussion: Baby CalingasanPelayo-Samson

GENERAL INFORMATION

• Baby Boy of J. C.• Patient is born full term 37 weeks by PA 2600

grams AGA cephalic presentation delivered by repeat LSCS to a 23 year old G2P1(1001) mother. Mother had a stable primary antenatal condition, had 2 pre-natal check-up c/o PGH. No maternal illnesses, no vices, no medications during pregnancy.

PHYSICAL EXAMINATION

DIFFERENTIALSDifferential Rule-in Rule-out

Hyaline Membrane Disease (+)tachypnea(+) grunting(+)retractions

-rare in term neonates-mother not GDM-worsens / peaks at 48-36 hours-CXR findings:ground glass appearance, air bronchogram, diffuse reticulogranular infiltrates

Transient Tachypnea of the Newborn

-usually follows uneventful normal FT SVD or cesarean section

-Early onset tachypnea with or without retractions

(+) expiratory grunting

-cyanosis relieved by minimal 02-with rapid recovery in 3 days-PE: lungs clear w/o rales or rhonchiCXR: prominent pulmonary vascular markings (Sunburst pattern), overaeration, flat diaphragm-benign, self-limited course

Neonatal Pneumonia (+)tachypnea(+) grunting(+)retractions(+) cyanosis

Pre-natal history suggests infection-usually predisposed by pre-mature labor, PROM, increased IE-CBC usually: neutropenia, leukocytosis-cannot be fully ruled-out

Meconium Aspiration Syndrome

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

-cannot be fully ruled-out

LABS

DIAGNOSIS

Full term 37 weeks by PA 2600 grams AGA cephalic presentation delivered by repeat LSCS, AS 9,9

Meconium PneumonitisHyperbilirubinemia w/o set-upr/o Nosocomial sepsis

COURSE IN THE WARDS• Born at the 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 Ordered CBC with PC, Blood typing, ABG, Na, K, Cl,

Ca, CXR APL, Blood CS Venoclysis started with D10W (80) @ 9cc/hr NPO, Hgt q8 O2 support at 10 lpm/hood

ABGs7.189 21.4

51.2 -8.2

76% 91.4%

COURSE IN THE WARDS

• Admitted at NICU 3 on May 7, 2009Received with fair pulses BP 30-40/20’sGiven 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

COURSE IN THE WARDS

Due to persistent desaturation (O2 sats 80’s), patient intubated with MV settings 100%, 18/3, RR 60 LT 0.4

O2 sats improved to 98-100%ABGs orderedD10W increased to run for 10 cc/hourSTAT NaHCO3 5 meqs givenABGs ordered

ABGs after intubation7.283 18.5

38.8 -6.9

291 99.9%

ABGs after NaHCO37.407 17.80

28 -5

146 99.30

COURSE IN THE WARDS

• 1st HD, 1st DOLPWI: 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 D10 1MB Ca 300 @ 10cc/hr

CBC and Blood TypeBlood Type B positiveHgb 129Hct 0.386WBC 5.56Segmenters 0.697Lymphocytes 0.18Monocytes 0.101Eosinophils 0.016Platelet 227

ABGs7.468 10.50

14.40 -9.8

191 99.80

COURSE IN THE WARDS

Decrease RR to 50 then decrease by 2 q2 until 30

Decrease FiO2 by 5 q2 until 60%

COURSE IN THE WARDS

• 2nd HD, 2nd DOLMV setting at 80%, 18/3, 44, 0.4ABGs orderedOnce FiO2 60%, may start feeding with 5cc

EBM q3/OGT with SAP

ELECTROLYTESNa 143

K 3.9

Cl 108

Ca 1.6

COURSE IN THE WARDS

Start feeding 5cc EBM as ordered, if tolerated 3x, start increments: increase 5cc every feeding until 30cc

MV setting: 60% 18/5 26 0.4Wean FiO2 by 5 q2 til 21%Wean RR by 2 q2 til 10Extract ABGs at RR=10

COURSE IN THE WARDS

• 3rd HD, 3rd DOLPrepare for extubationPrepare O2 hood FiO2 30%MV settings at 21%, 18/3, 14, 0.4Revise inotropes: Dopamine 0.5cc + D5W 23.5

cc to run at 1cc/hour then consume then discontinue

COURSE IN THE WARDS

s/p extubationPlaced on O2 hood FiO2 30%Racemic epinephrine nebulization started to

continue 2 more doses 15 minutes apartPatient noted to be jaundiced up to thighsFor TB DB IBIncrease feeding to 35cc q3/OGT

COURSE IN THE WARDS

For CPT with proper shieldsDopamine discontinuedNCPAP 30% PEEP 5ABGsNoted vomiting with feeding; abdomen soft

but distendedFeeding decreased to 30cc

ABGs7.324 20.3

38.6 -4.7

84 95.6

COURSE IN THE WARDS

• 4th HD, 4th DOLIncreased feeding to 35ccTB DB IB notedMaintain on phototherapyPWI: FT 37 wks by PA, 2600 g, AGA, cephalic,

delivered via primary LSCS, LBG, AS 5,9; Neonatal pneumonia; Hyperbilirubinemia no set-up

TB DB IBTB 15.9

DB 0

IB 15.9

COURSE IN THE WARDS 13cc of feeding residual noted; no abdominal

distention Feeding deferred Wean FiO2 by 5 q2 until 21% Coffee-ground noted NPO Start Famotidine 1mg IV q12 Give Vit K 2mg slow IV push ABGs ordered at 25% PEEP 5

ABGs 7.329 21.80

40.80 -3.5

68 92.40

COURSE IN THE WARDS

• 5th HD, 5th DOLPWI: 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

COURSE IN THE WARDS

For repeat CBC with PC, blood CS, eletrolytesTo start Ceftazidime (50mkd) 130mg IV q12hNPOIVF revised to: D10 1MB Ca 400 @ 13cc/hrCXR: meconium pneumonitis with atelectasis

on the rightPlease put patient on right side up

DISCUSSION

MAS

MAS

HYPERBILIRUBENEMIA

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