CASE DISCUSSION

Ontok, Abdul-AzizPelayo, May AngelaRodriguez, MelissaSamson, Edgardo

Manzano, LuisJocelyn, Eds

HISTORY

• 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

• 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

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

Antenatal History

• Onset of Uterine Activity: Spontaneous

• Intensity of Contractions: Moderate

• Membrane Status: Intact• Analgesia: None

Labor

• Mode: Abdominal • Amniotic Fluid: Slightly Meconium Stained

• Analgesia: Subarachnoid Block

Delivery

• APGAR Score: 5, 9• Resuscitation:

Supplementary O2 10 LPM via hood

Positive Pressure-Ventilation

Immediate Neonatal Period

• (-) Hypertension• (-) Diabetes Mellitus• (-) Bronchial Asthma• (-) Blood Dyscrasias

Family History

PHYSICAL EXAMINATION

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

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

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

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

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

PRIMARY IMPRESSION

• 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

(+) history of meconium staining

baby received non-vigorous, HR 60s, poor muscle tone, with no response

(+) tachypnea (+) grunting (+) retractions

MECONIUM PNEUMONITIS

DIFFERENTIAL DIAGNOSIS

• 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

• 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

• 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

COURSE IN THE WARD

• 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

• 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

ARTERIAL BLOOD GAS

On Admission

7.189 21.451.2 -8.276% 91.4%

Respiratory Acidosis

• 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

• 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

ARTERIAL BLOOD GASafter intubation

On Admission

7.283 18.5

38.8 -6.9

291 99.9%

ARTERIAL BLOOD GASafter NaHCO3

On Admission

7.407 17.80

28 -5

146 99.30

• 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

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

ARTERIAL BLOOD GAS

1st HD, 1st DOL

7.468 10.50

14.40 -9.8

191 99.80

• Decrease RR to 50 then decrease by 2 q2 until 30

• Decrease FiO2 by 5 q2 until 60%

1st HD, 1st 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

2nd HD, 2nd DOL

ELECTROLYTES

2nd HD, 2nd DOL

Na 143K 3.9Cl 108Ca 1.6

• 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

• 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

• 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

• Patient noted to be jaundiced up to thighs

• For TB DB IB

• Increase feeding to 35cc q3/OGT

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

3rd HD, 3rd DOL

ARTERIAL BLOOD GAS

3rd HD, 3rd DOL

7.324 20.3

38.6 -4.7

84 95.6

• 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

TOTAL BILI., DIRECT BILI., INDIRECT BILIRUBIN

4th HD, 4th DOL

TB 15.9

DB 0

IB 15.9

• 13cc of feeding residual noted; no abdominal distention• Feeding deferred • Wean FiO2 by 5 q2 until 21%• Coffee-ground noted

4th HD, 4th DOL

• NPO

• Start Famotidine 1mg IV q12

• Give Vit K 2mg slow IV push

• ABGs ordered at 25% PEEP 5

4th HD, 4th DOL

ARTERIAL BLOOD GAS

4th HD, 4th DOL

7.329 21.80

40.80 -3.5

68 92.40

• 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

• 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

CHEST X-RAY

Meconium Pneumonitis with atelectasis on the right

5th HD, 5th DOL

MECONIUM ASPIRATION SYNDROME