NICU Case Discussion: Baby Calingasan
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NICU Case Discussion: Baby Calingasan

Pelayo. -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. .

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NICU Case Discussion: Baby Calingasan




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Presentation on theme: "NICU Case Discussion: Baby Calingasan"— Presentation transcript:

Slide1

NICU Case Discussion: Baby Calingasan

Pelayo-Samson

Slide2

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.

Slide3

PHYSICAL EXAMINATION

Slide4

Slide5

DIFFERENTIALS

Differential

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

rhonchi

CXR:

prominent pulmonary

vascular markings (Sunburst pattern),

overaeration

, flat diaphragm

-benign, self-limited course

Slide6

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

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LABS

Slide8

DIAGNOSIS

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

Meconium Pneumonitis

Hyperbilirubinemia w/o set-up

r/o Nosocomial sepsis

Slide9

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

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ABGs

7.189

21.4

51.2

-8.2

76%

91.4%

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COURSE IN THE WARDS

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

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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 ordered

D10W increased to run for 10 cc/hour

STAT NaHCO3 5 meqs given

ABGs ordered

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ABGs after intubation

7.283

18.5

38.8

-6.9

291

99.9%

Slide14

ABGs after NaHCO3

7.407

17.80

28

-5

146

99.30

Slide15

COURSE IN THE WARDS

1

st

HD, 1

st

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 D10 1MB Ca 300 @ 10cc/hr

Slide16

CBC and Blood Type

Blood Type

B positive

Hgb

129

Hct

0.386

WBC

5.56

Segmenters

0.697

Lymphocytes

0.18

Monocytes

0.101

Eosinophils

0.016

Platelet

227

Slide17

ABGs

7.468

10.50

14.40

-9.8

191

99.80

Slide18

COURSE IN THE WARDS

Decrease RR to 50 then decrease by 2 q2 until 30

Decrease FiO2 by 5 q2 until 60%

Slide19

COURSE IN THE WARDS

2

nd

HD, 2

nd

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

Slide20

ELECTROLYTES

Na

143

K

3.9

Cl

108

Ca

1.6

Slide21

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 0.4

Wean FiO2 by 5 q2 til 21%

Wean RR by 2 q2 til 10

Extract ABGs at RR=10

Slide22

COURSE IN THE WARDS

3

rd

HD, 3

rd

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

Slide23

COURSE IN THE WARDS

s/p extubation

Placed on O2 hood FiO2 30%

Racemic epinephrine nebulization started to continue 2 more doses 15 minutes apart

Patient noted to be jaundiced up to thighs

For TB DB IB

Increase feeding to 35cc q3/OGT

Slide24

COURSE IN THE WARDS

For CPT with proper shields

Dopamine discontinued

NCPAP 30% PEEP 5

ABGs

Noted vomiting with feeding; abdomen soft but distended

Feeding decreased to 30cc

Slide25

ABGs

7.324

20.3

38.6

-4.7

84

95.6

Slide26

COURSE IN THE WARDS

4

th

HD, 4

th

DOL

Increased feeding to 35cc

TB DB IB noted

Maintain 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

Slide27

TB DB IB

TB

15.9

DB

0

IB

15.9

Slide28

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

Slide29

ABGs

7.329

21.80

40.80

-3.5

68

92.40

Slide30

COURSE IN THE WARDS

5

th

HD, 5

th

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

Slide31

COURSE IN THE WARDS

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

CXR: meconium pneumonitis with atelectasis on the right

Please put patient on right side up

Slide32

DISCUSSION

Slide33

MAS

Slide34

MAS

Slide35

HYPERBILIRUBENEMIA

Slide36

THANK YOU!

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