Ｒ1 歐宗頴 2016/11/04 case discussion

case demography Name: 阮Ｏ嬌之子, 1786xxxx Age: 7-day-old, PMA: 34wks Gender: boy Admission: 2016/10/19 Chief complaint: Lethargy and poor feeding since 7d/o

prenatal history lower abdominal pain G4P2AA2 Maternal: 34y/o, GDM(-), PIH(-), preeclampsia(-) Level II sonography: normal HBsAg(-), HBeAg(-), VDRL(-), HIV(-), Rubella IgG(+) Amniocentesis: not performed GBS: not performed lower abdominal pain preterm premature rupture of membrane Tocolysis with Yutopar, betamethasone, Cefazolin 10/16 32+5wk 10/19 GA33wk NST: severe variable deceleration emergent Cesarean section

Clinical course G4P2, GA33wk, C/S due to variable deceleration 10/19 G4P2, GA33wk, C/S due to variable deceleration BBW: 2008g(25-50th) BL: 44cm(50%) HC: 33cm(25-50%) Apgar score: 6 (hypotonia) 8 subcostal retraction, desaturation(70%)

10/19

Clinical course temperature instability off incubator GA33wk, C/S, AGA 10/19 10/24 temperature instability off incubator GA33wk, C/S, AGA fetal distress with TTN Ampicillin & Gentamicin for 3 days trophic feeding with SSC20 since 12th hr

Clinical course temperature instability off incubator 14:30 Calcitriol 10/19 10/24 10/25 GA33+6wk temperature instability off incubator 14:30 Calcitriol GA33wk, C/S, AGA fetal distress with TTN Ampicillin & Gentamicin for 3 days trophic feeding with SSC20 since 12th hr

Clinical course temperature instability temperature instability 10/19 10/24 10/25 GA33+6wk temperature instability temperature instability off incubator 14:30 Calcitriol GA33wk, C/S, AGA fetal distress with TTN Night- Lethargy, poor feeding Fever(-), Irritability(-) Apnea(-), Bradycardia(-), Desaturation(-), Tachypnea(-) N/V(-), Stool passage change(-), Bloody stool(-) Physical examination: Fontanelle bulging(-) Abdomen: soft and flat(28cm), normoactive bowel sounds, tenderness(-), mass(-), hepatospelnomegaly(-), rigidity(-), hernia(-) Muscle tone: flaccid, poor sucking, focal weakness(-)

Clinical course Neosure 303 95 temperature instability off incubator 10/19 10/24 10/25 GA33+6wk temperature instability off incubator Night- Lethargy, poor feeding GA33wk, C/S, AGA fetal distress with TTN trophic feeding with SSC20 since 12th hr Neosure 303 235 195 155 115 95 SSC20 35 75 150 120 100 40 60 80 20cc/kg/d +6 GA34wk

10/26 16:00

Impression Necrotizing enterocolitis, stage IA hypocalcemia, suspect insufficient intake related prematurity, GA33wks respiratory distress, favor TTN

Clinical course temperature instability off incubator 14:30 Calcitriol 10/19 10/24 10/25 GA33+6wk temperature instability off incubator 14:30 Calcitriol GA33wk, C/S, AGA fetal distress with TTN Night- Lethargy, poor feeding 10/26 GA34wk NPO Ceftriaxone Amikacin Metronidazole Night- Lethargy recovery

10/26 16:00 10/26 23:30

segmental dilated small loops favor reflex ileus 10/27 13:00 10/27 21:30 segmental dilated small loops favor reflex ileus segmental bowel wall swelling

Clinical course temperature instability off incubator 14:30 Calcitriol 10/19 10/24 10/25 GA33+6wk temperature instability off incubator 14:30 Calcitriol GA33wk, C/S, AGA fetal distress with TTN Night- Lethargy, poor feeding 10/26 GA34wk 10/30 11/02 35wk NPO Ceftriaxone Amikacin Metronidazole trophic feeding with neosure 54cc/kg/d Night- Lethargy recovery

diagnosis Necrotizing enterocolitis, stage IA hypocalcemia, suspect insufficient intake related prematurity, GA33wks respiratory distress, favor TTN

necrotizing enterocolitis discussion

necrotizing enterocolitis introduction necrotizing enterocolitis one of the most common gastrointestinal emergencies in the newborn inflammation invasion of enteric gas forming organisms dissection of gas into the muscularis and portal venous system

pneumomatosis

unspecific feeding intolerance Vital signs change, lethargy OB(+) bloody stool ileus pneumomatosis

Vital signs change, lethargy OB(+) bloody stool ileus Absence bowel sounds pneumomatosis mild acidosis thrombocytopenia ascites portal vein gas

Vital signs change, lethargy OB(+) bloody stool ileus Absence bowel sounds pneumomatosis mild acidosis thrombocytopenia ascites portal vein gas Unstable Vital Signs, DIC, neutropenia peritonitis pneumoperitoneum

2016 Oct. 16

Take home message Risk factors for NEC unspecific presentation early recognition, early intervention prophylaxis

thanks for your attention

CCr 18 FeNa 0.3% (1-FeP) 84% FeCa 0.72% Albumin 3.1 BUN 4 Cr 0.62 Ccr 136 K 4.9 cCa 7.8 P 10.2 Mg 1.6 ALK-P 149 AMON 31 CRP <7 CCr 18 FeNa 0.3% (1-FeP) 84% FeCa 0.72%