CASE DISCUSSION
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Transcript of CASE DISCUSSION
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CASE DISCUSSION
Ontok, Abdul-AzizPelayo, May AngelaRodriguez, MelissaSamson, Edgardo
Manzano, LuisJocelyn, Eds
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HISTORY
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• 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
Identifying Data
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• OB Index: G2P2 (2002)• Previous Pregnancy:
Date: 2007Sex: MaleBW: 2.7 kgPlace: Perpetual Help HospitalDelivery Type: 1o Low-segment C.S.AOG: Full TermComplications: Cephalopelvic Disroportion
Maternal Obstetrical History
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• LMP: September 04, 2008• Prenatal Checkups: 2 at PGH• Medications Taken: None• Illnesses/Infection: None• Alcohol/Tobacco Use: None
Antenatal History
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• Onset of Uterine Activity: Spontaneous
• Intensity of Contractions: Moderate
• Membrane Status: Intact• Analgesia: None
Labor
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• Mode: Abdominal • Amniotic Fluid: Slightly Meconium Stained
• Analgesia: Subarachnoid Block
Delivery
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• APGAR Score: 5, 9• Resuscitation:
Supplementary O2 10 LPM via hood
Positive Pressure-Ventilation
Immediate Neonatal Period
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• (-) Hypertension• (-) Diabetes Mellitus• (-) Bronchial Asthma• (-) Blood Dyscrasias
Family History
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PHYSICAL EXAMINATION
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PHYSICAL EXAM
• GENERAL APPEARANCE:vigorously crying with active motor activity
• VITAL SIGNS: T: 36.6oC HR: 130 bpm RR: 50 cpmWt: 2600 g Lt: 49 cm HC: 32.5 cmCC: 31 cm AC: 28 cm
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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
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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
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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
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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
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PRIMARY IMPRESSION
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• Meconium Pneumonitis
• 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
Primary Impression
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(+) history of meconium staining
baby received non-vigorous, HR 60s, poor muscle tone, with no response
(+) tachypnea (+) grunting (+) retractions
MECONIUM PNEUMONITIS
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DIFFERENTIAL DIAGNOSIS
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• 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
1. Hyaline Membrane Disease
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• 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
2. Transient Tachypnea of the NB
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• 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
3. Neonatal Pneumonia
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COURSE IN THE WARD
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• 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
On Admission
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• 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
On Admission
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ARTERIAL BLOOD GAS
On Admission
7.189 21.451.2 -8.276% 91.4%
Respiratory Acidosis
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• 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
On Admission
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• 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 ordered• D10W increased to run for 10 cc/hour• STAT NaHCO3 5 meqs given• ABGs ordered
On Admission
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ARTERIAL BLOOD GASafter intubation
On Admission
7.283 18.5
38.8 -6.9
291 99.9%
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ARTERIAL BLOOD GASafter NaHCO3
On Admission
7.407 17.80
28 -5
146 99.30
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• 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
1st HD, 1st DOL
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CBC AND BLOOD TYPE
1st HD, 1st DOL
BLOOD TYPE B positiveHGB 129HCT 0.386WBC 5.56SEGMENTERS 0.697LYMPHOCYTES 0.18MONOCYTES 0.101EOSINOPHILS 0.016PLATELET 227
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ARTERIAL BLOOD GAS
1st HD, 1st DOL
7.468 10.50
14.40 -9.8
191 99.80
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• Decrease RR to 50 then decrease by 2 q2 until 30
• Decrease FiO2 by 5 q2 until 60%
1st HD, 1st DOL
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• MV setting at 80%, 18/3, 44, 0.4
• ABGs ordered
• Once FiO2 60%, may start feeding with 5cc EBM q3/OGT with SAP
2nd HD, 2nd DOL
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ELECTROLYTES
2nd HD, 2nd DOL
Na 143K 3.9Cl 108Ca 1.6
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• 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
2nd HD, 2nd DOL
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• 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
3rd HD, 3rd DOL
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• S/P Extubation
• Placed on O2 hood FiO2 30%
• Racemic epinephrine nebulization started to continue 2 more doses 15 minutes apart
3rd HD, 3rd DOL
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• Patient noted to be jaundiced up to thighs
• For TB DB IB
• Increase feeding to 35cc q3/OGT
3rd HD, 3rd DOL
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• For CPT with proper shields• Dopamine discontinued• NCPAP 30% PEEP 5• ABGs• Noted vomiting with feeding; abdomen soft but distended
• Feeding decreased to 30cc
3rd HD, 3rd DOL
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ARTERIAL BLOOD GAS
3rd HD, 3rd DOL
7.324 20.3
38.6 -4.7
84 95.6
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• 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
4th HD, 4th DOL
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TOTAL BILI., DIRECT BILI., INDIRECT BILIRUBIN
4th HD, 4th DOL
TB 15.9
DB 0
IB 15.9
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• 13cc of feeding residual noted; no abdominal distention• Feeding deferred • Wean FiO2 by 5 q2 until 21%• Coffee-ground noted
4th HD, 4th DOL
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• NPO
• Start Famotidine 1mg IV q12
• Give Vit K 2mg slow IV push
• ABGs ordered at 25% PEEP 5
4th HD, 4th DOL
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ARTERIAL BLOOD GAS
4th HD, 4th DOL
7.329 21.80
40.80 -3.5
68 92.40
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• 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
5th HD, 5th DOL
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• 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
5th HD, 5th DOL
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CHEST X-RAY
Meconium Pneumonitis with atelectasis on the right
5th HD, 5th DOL
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MECONIUM ASPIRATION SYNDROME