case discussion

CASE DISCUSSION

Legaspi, LuisOntok, Abdul-AzizPayumo, Edelissa

Pelayo, May AngelaRodriguez, MelissaSamson, Edgardo

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

History of Present Illness

HR 60’s, limp, acrocyanotic, with no responseHR 50’s, some flexion, acrocyanotic, (+) grimaceHR 100’s, some flexion, acrocyanotic, (+) gruntingHR 130’s, active, acrocyanotic, (+) crying, RR 50-60(+) Grunting, (+) retractions

NICU 3

Thermoregulation, Suctioning, Tactile stimulation

Thermoregulation, Suctioning, Tactile stimulation, PPV

Thermoregulation, Given blow by O2, Stimulation

Weaned off from O2

Placed on O2 support via 10 lpm

• 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

• GENERAL APPEARANCE:limp, in respiratory distress

• 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

• 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

• EARS: (-) low-set ears, formed, firm with instant recoil

• NOSE:(+) alar flaring, both nostrils patent, (-) discharges

• 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

• HEART:adynamic precordium, (-) thrills, normal rate, regular rhythm, (-) murmur

• ABDOMEN:globular but not distended, nonpalpable liver

• UMBILICUS:translucent, (-) meconium stained, 2 arteries and 1 vein

• BACK:lanugo with bald areas, (-) dimpling, straight spine

DIFFERENTIAL DIAGNOSIS

DIFFERENTIAL RULE-IN RULE-OUT

Hyaline Membrane

Disease

• (+) Grunting• (+) Retractions

•Rare in term neonates•Mother not GDM•Worsens/peaks at 48-36 hours

Transient Tachypnea of the Newborn

•Usually follows an uneventful normal FT SVD or CS•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•Benign, self-limited course


Neonatal Pneumonia


• Pre-natal history suggests infection• Predisposed by pre-mature labor, inc-reased IE, PROM•Cannot be fully ruled-out

Meconium Aspiration Syndrome

•Meconium staining•Non-vigorous, HR 60s, poor muscle tone, (-) response• (+) Grunting• (+) Retractions

•Cannot be fully ruled-out


Neonatal Sepsis


•Cannot be fully ruled out

PRIMARY WORKING IMPRESSION

• Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9

• Meconium Aspiration Syndrome vs. Neonatal Pneumonia

• R/O sepsis

COURSE IN THE WARD

• Born on May 7, 2009, 4:57 p.m.

• Started on Piperacillin-Tazobactam (75mkd) 195 mg IV q12

• Started on Amikacin (15mkd) 40 mg IV OD

Catcher’s Area

an extended-spectrum penicillin: improved activity against gram-negative organisms but can be

destroyed by -lactamases

-lactamase inhibitor

has synergistic effect with penicillins

• Diagnostics:> CBC with PC > Na, K, Cl, Ca, > Blood typing > CXR APL> ABG > Blood C/S

• Venoclysis with D10W (80) @ 9cc/hr• NPO, Hgt q8• O2 support at 10 lpm/hood

Catcher’s Area

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Catcher’s Area

COMPONENT

05/07/09 NORMAL VALUES

WBC 5.56 5.0 – 30.0RBC 3.74 4.0 – 6.0HGB 129 120-180HCT 0.386 0.370 – 0.540Platelet 227 150 – 450Neutrophil 0.697 0.500 – 0.700Lymphocyte 0.182 0.200 – 0.500Monocyte 0.101 0.020 – 0.090Eosinophil 0.016 0.000 – 0.060Basophils 0.004 0.000 – 0.020

COMPLETE BLOOD COUNT

Catcher’s AreaARTERIAL BLOOD GAS

pH 7.189

pCO2 51.20

pO2 76.00

HCO3 19.80

BEb -8.2O2sat 91.40%

COMBINED METABOLIC AND RESPIRATORY ACIDOSIS

3rd Hour of LifeS: (+) hypotension, (-) hypothermia, (-)

dyspneaO: pink all over, some flexion of

extremities, weak cryRR:24 HR:132 BP:30-40 T:36.6o

O2:85-95% (-) alar flaring, (-) circumoral cyanosisequal chest expansion, (-) grunting,

clear breath soundsadynamic precordium, (-) tachycardia,

(-) murmurglobular, soft, (-) massesgood capillary refill, fair pulses

A: Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia

3rd Hour of LifeP:

Given total of 50 cc PNSS IV bolus

Started on Dopamine @ 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc)

UVC inserted

5th Hour of LifeS: (+) persistent desaturation, (-)

tachycardia, (+) dyspneaO: acrocyanotic, some flexion of

extremities, weak cryRR:72 HR:144 BP:40-50 T:36.7o

O2:80% (+) alar flaring, (-) circumoral cyanosisequal chest expansion, (+) ICS

retractions, (+) gruntingadynamic precordium, (-) tachycardia,

(-) murmurglobular, soft, (-) massesgood capillary refill, fair pulses

A: Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia

5th Hour of LifeP:

Intubated with MV settings: FiO2100%, 18/3, RR 60 LT 0.4

D10W increased to run for 10 cc/hour

5th Hour of LifeARTERIAL BLOOD GAS

(post-intubation)pH 7.252 pCO2 39.70pO2 188.00

HCO3 17.70

BEb -8.5O2sat 99.50%UNCOMPENSATED METABOLIC

ACIDOSIS(NaHCO3 5 meqs)

7th Hour of LifeARTERIAL BLOOD GAS

(post-NaHCO3)

pH 7.407pCO2 28.00

pO2 146.00

HCO3 17.80

BEb -5O2sat 99.30%COMPENSATED REPIRATORY

ALKALOSIS

1st Day of LifeS: (-) desaturation, (-) tachycardia, (-)

dyspnea, (-) fever,(+) BM x1, (+) UO x2, (-) jaundice

O: pink all over, good muscle tone, awakeRR:56 HR:128 T:36.7o O2:99% (-) alar flaring, (-) circumoral cyanosisequal chest expansion, (-) ICS

retractions, (-) gruntingadynamic precordium, (-) tachycardia,

(-) murmurglobular, soft, (-) massesgood capillary refill, strong pulses

1st Day of LifeCHEST X-RAY

CHEMICAL PENUMONITIS

1st Day of LifeBLOOD CHEMISTRY

CALCIUM 1.60 mmol/L

(2.12 – 2.52)

SODIUM 143 mmol/L (136 – 145)

POTASSIUM

3.9 mmol/L (3.50 – 5.10)

CHLORIDE

108 mmol/L (98 – 107)HYPOCALCEMIA

1st Day of LifeARTERIAL BLOOD GAS

pH 7.468pCO2 14.40

pO2 191.00

HCO3 10.50

BEb -9.8O2sat 99.80%COMPENSATED RESPIRATORY

ALKALOSIS

1st Day of LifeA: Full Term, 37 weeks by PA, 2600 g,

AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN

precaution; r/o Sepsis

P: IVF shifted to D10IMB Ca 300 @

10cc/hr Decreased RR to 50 then by 2 every 2

hrs until 30 Decreased FiO2 by 5 every 2 hours

until 60%

Why?

2nd Day of LifeS: (-) desaturation, (-) tachycardia, (-)

dyspnea, (-) fever,(+) BM x2, (+) UO x3, (-) jaundice

O: pink all over, good muscle tone, asleepRR:44 HR:136 T:37.2o O2:99% (-) alar flaring, (-) circumoral cyanosisequal chest expansion, (-) ICS

retractions, (-) gruntingadynamic precordium, (-) tachycardia,

(-) murmurglobular, soft, (-) massesgood capillary refill, strong pulses

2nd Day of LifeARTERIAL BLOOD GAS

pH 7.360pCO2 32.70pO2 149.00

HCO3 18.40BEb -5.1O2sat 99.20%NORMAL ARTERIAL BLOOG GAS

(????)

2nd Day of LifeA: Full Term, 37 weeks by PA, 2600 g,

AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN

precaution; r/o Sepsis

P: Once FiO2 60%, may start feeding with

5cc EBM every 3 hours per with strict aspiration precaution

2nd Day of LifeP:

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 every 2 hours until 21%

Wean RR by 2 every 2 hours until 10

Extract ABGs at RR=10

3rd Day of Life, A.M.S: (-) tachycardia, (-) dyspnea, (-) fever, (-)

jaundice

O: pink all over, good muscle tone, asleepRR:44 HR:136 T:37.2o O2:99% (-) alar flaring, (-) circumoral cyanosisequal chest expansion, (-) ICS retractions,

(-) gruntingadynamic precordium, (-) tachycardia, (-)

murmurglobular, soft, (-) massesgood capillary refill, strong pulses

A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

3rd Day of Life, A.M.ARTERIAL BLOOD GAS

(post-extubation)pH 7.324pCO2 38.60pO2 84.00HCO3 20.30BEb -4.7O2sat 95.60%

??????????????

3rd Day of Life, A.M.P:

Extubated Placed on O2 hood FiO2 30% Revised inotropes: Dopamine 0.5cc + D5W 23.5 cc to run at 1cc/hour, then consume, then discontinue

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

3rd Day of Life, P.M.S: (-) fever, (+) jaundice, (+) coffe-ground

material/ogt

O: pink all over, good muscle tone, asleepRR:48 HR:152 T:36.7o

(-) alar flaring, (-) circumoral cyanosisequal chest expansion, (-) ICS retractions,


murmurdistended, soft, (-) massesgood capillary refill, strong pulses

A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

3rd Day of Life, P.M.P:

For TB DB IB For CPT with proper shields Dopamine discontinued NCPAP 30% PEEP 5 ABGs Feeding decreased to 30cc

4th Day of LifeS: (-) dyspnea, (-) fever, (+) jaundice, (+)

vomiting





A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; Hyperbilirubinemia no set-up

4th Day of LifeTOTAL, DIRECT, INDIRECT

BIL.TB 16.1 mg/dl (10.00 –

180.00)DB 0 mg/dl (0.00 – 10.00)

IB 16.1 mg/dl (10.00 – 180.00)

NORMAL

4th Day of LifeP:

Maintained on phototherapy NPO Wean FiO2 by 5 q2 until 21% Started on Famotidine 1mg IV q12

Given Vit. K 2mg slow IV push ABGs ordered at 25% PEEP 5

Why?

Why?

5th Day of LifeS: (-) dyspnea, (-) fever, (+) jaundice, (+)

vomiting





A: Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; Hyperbilirubinemia no set-up

4th Day of LifeARTERIAL BLOOD GAS

pH 7.329pCO2 40.80pO2 68.00HCO3 21.80BEb -3.5O2sat 92.40%

??????????????

4th Day of LifeCHEST X-RAY

ATELECTASIS, RIGHT UPPER LOBEATELECTASIS/CONSOLIDATION, MEDIAL SEGMENT

OF RLL

5th Day of LifeP:

For repeat CBC with PC, blood CS, eletrolytes

To start Ceftazidime (50mkd) 130mg IV q12h

IVF revised to: D10IMB Ca 400 @ 13cc/hr

Please put patient on right side up

Why?

Why?

6th Day of Life

COMPONENT 05/07/09 05/12/09 NORMAL VALUES

WBC 5.56 24.42 5.0 – 30.0RBC 3.74 3.66 4.0 – 6.0HGB 129 122 120-180HCT 0.386 0.358 0.370 – 0.540Platelet 227 142 150 – 450Neutrophil 0.697 0.77 0.500 – 0.700Lymphocyte 0.182 .07 0.200 – 0.500Monocyte 0.101 0.10 0.020 – 0.090Eosinophil 0.016 0.006 0.000 – 0.060Basophils 0.004 0.000 – 0.020

COMPLETE BLOOD COUNT

6th Day of LifeBLOOD CHEMISTRY

TEST 5/9/09 5/12/09 Normal Values

CALCIUM 1.60 mmol/L 1.92 mmol/L

(2.12 – 2.52)

SODIUM 143 mmol/L 140 mmol/L

(136 – 145)

POTASSIUM

3.9 mmol/L 4.3 mmol/L (3.50 – 5.10)

CHLORIDE

108 mmol/L 106 mmol/L

(98 – 107)

6th Day of LifeTOTAL, DIRECT, INDIRECT

BIL.TEST 5/9/09 5/12/09 Normal

ValuesTB 16.1

mg/dl14.6 mg/dl

(10.00 – 180.00)

DB 0 mg/dl 0.0 mg/dl

(0.00 – 10.00)

IB 16.1 mg/dl

14.6 mg/dl

(10.00 – 180.00)

MECONIUM ASPIRATION SYNDROME

Introduction•Meconium-stained amniotic fluid may be aspirated during labor and delivery, causing neonatal respiratory distress.

•Because meconium is rarely found in the amniotic fluid prior to 34 weeks' gestation, meconium aspiration chiefly affects infants at term and postterm.

Introduction3 major constituents of meconium:

1. Intestinal secretions2. Mucosal cells3. Solid elements of swallowed

amniotic fluid are the 3 major solid constituents of meconium.

Water - major liquid constituent, (85-95%)

Etiology• Placental insufficiency• Maternal hypertension • Preeclampsia• Oligohydramnios• Maternal drug abuse (tobacco, cocaine)

Etiology•Maternal infection/chorioamnionitis

• Inadequate removal of meconium from the airway prior to the first breath

•Use of positive pressure ventilation (PPV) prior to clearing the airway of meconium

PathophysiologyFetal hypoxic stress

(head or cord compression)↓Vagal stimulation↓

Mature gastrointestinal tract↓Peristalsis↓

Rectal sphincter relaxation↓Meconium passage

PathophysiologyMeconium + amniotic fluid

↓

1. perinatal bacterial infection 2. erythema toxicum3. stained amniotic fluid

aspiration

PathophysiologyAspiration induces hypoxia via 3 major pulmonary effects:

1. airway obstruction2. surfactant dysfunction3. chemical pneumonitis

Pathophysiology1. Airway obstruction

• Complete obstruction - atelectasis• Partial obstruction - ball-valve effect

Pathophysiology2. Surfactant dysfunction

• free fatty acids of the meconium (eg, palmitic, stearic, oleic), have a higher minimal surface tension than surfactant

• Meconium strip it from the alveolar surface, resulting in diffuse atelectasis

Pathophysiology3. Chemical pneumonitis

• Enzymes, bile salts, and fats in meconium irritate the airways and parenchyma, causing a release of cytokines

• results in a diffuse pneumonia that may begin within a few hours of aspiration

HistoryMeconium in amniotic fluid - required to cause meconium

aspiration syndrome (MAS)

Green urine - less than 24 hours after birth - meconium pigments absorbed

by lungs, excreted in urine

Clinical ManifestationsCyanosis •End-expiratory grunting •Alar flaring • Intercostal retractions • Tachypnea •Barrel chest in the presence of air trapping •Auscultated rales and rhonchi (in some cases)

Clinical ManifestationsYellow-green staining •Fingernails•Umbilical cord •Skin

Laboratory Studies

Acid-base status • Metabolic acidosis from perinatal stress

• Respiratory acidosis from parenchymal disease and persistent pulmonary hypertension of the newborn (PPHN).

Laboratory StudiesSerum electrolytes• sodium, potassium, and calcium• common perinatal stress complications:

1. syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

2. acute renal failure are frequent of

Laboratory StudiesCBC Count •In utero or perinatal blood loss, as well as infection, contributes to postnatal stress•Hemoglobin and hematocrit

- ensure adequate oxygen-carrying capacity •Neutropenia or neutrophilia

- may indicate perinatal bacterial infection

Chest Findings

Air trapping and hyperexpansion from airway obstruction.

Chest Findings

Acute atelectasis

Chest Findings

Pneumomedia-stinum from gas trapping and air leak

Chest Findings

Left pneumothorax with depressed diaphragm and minimal mediastinal shift because of noncompliant lungs

Chest Findings

Diffuse chemical pneumonitis from constituents of meconium

Chest Findings• Gross overaeration of the lungs and

bilateral nodular infiltrates

• The nodular infiltrates represent areas of patchy or focal alveolar atelectasis and the overaerated spaces in between, compensatroy, focal alveolar overdistension

ManagementMeconium Aspiration

↓Intubation

↓Suctioning

(Tracheal suctioning)

ManagementNo clinical trials justify suctioning

based on the consistency of meconium.

Avoid:•Squeezing the chest of the baby •Inserting a finger into the mouth of the baby

Guidelines for Management of a Baby Exposed to Meconium

by AAPNRPNOT VIGOROUS

(minimal or absent respiratory effort, poor muscle tone, or HR <100 beats/min)

↓Direct laryngoscopy intubation

and tracheal suctioning(Suction for no longer than 5 seconds)

↓NO MECONIUM IS RETRIEVED

DO NOT repeat Intubation and suction

MECONIUM IS RETRIEVED, NO BRADYCARDIA

Reintubate and suction


by AAPNRPVIGOROUS

(good respiratory effort, crying, good muscle tone, and HR >100 beats/min)

↓DO NOT electively intubate.

↓Clear secretions and meconium

from the mouth and nose with a bulb syringe or a

large-bore suction catheter


by AAPNRP

In either case,

The remainder of the initial resuscitation steps should ensue and include:

drying, stimulating, repositioning, and oxygen administration as necessary

Continued care in the NICU

Maintain an OPTIMAL THERMAL ENVIRONMENT

Minimal handling

SEDATION - to decrease agitation


Continue RESPIRATORY CARE

• Oxygen therapy - hood or positive pressure for adequate arterial oxygenation• Mechanical ventilation - minimize the mean airway pressure - short inspiratory time - oxygen saturations 90-95%


SURFACTANT THERAPY

Nitric Oxide - pulmonary vasodilator of choice in PPHN

SYSTEMIC BLOOD VOLUME BLOOD PRESSURE (Volume expansion, transfusion therapy, and systemic vasopressors)

decrease: right-to-left shunt via PDA

Complications1. Chronic lung disease2. Infections

Prognosis Most with complete recovery of

pulmonary function

Intrapartum events initiating meconium passage may cause long-term neurologic deficits:• CNS damage• seizures• mental retardation• cerebral palsy

HYPERBILIRUBINEMIA

Pathophysiology• Yellow color usually results from

accumulation of unconjugated, nonpolar, lipid-soluble bilirubin pigment in the skin

• May be due in part to deposition of pigment from conjugated bilirubin

• Elevated levels of indirect, unconjugated bilirubin potentially neurotoxic

Etiology1.Increase load of bilirubin to the

liver•Hemolytic anemia, polycythemia, shortened red cell life, increased enterohepatic circulation, infection

2.Damaged or reduced activity of the transferase enzyme or other related enzymes• Genetic deficiency, hypoxia, infection, thyroid deficiency

Etiology3.Blocked transferase

enzyme

4.Absence or decreased amounts of enzyme or reduced bilirubin uptake by liver cells•Genetic defect, prematurity

Differential Diagnosis• Jaundice appearing after the 3rd

day and within the 1st week suggests bacterial sepsis or urinary tract infection

• Other causes: syphilis, toxoplasmosis, CMV, enterovirus

Management•Regardless of the cause, goal of therapy is to prevent indirect-reacting bilirubin related neurotoxicity

• Tx: phototherapy and exchange therapy

End...

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case discussion

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