Ontok, Abdul-Aziz Pelayo, May Angela Rodriguez, Melissa Samson, Edgardo Manzano, Luis Jocelyn, Eds

Baby Boy J.C. Baby Boy J.C. Full Term, 37 weeks by P.A. Full Term, 37 weeks by P.A g, appropriate for G.A g, appropriate for G.A. Cephalic presentation Cephalic presentation Repeat low-segment C.S. Repeat low-segment C.S. 23 year old, G 2 P 2 23 year old, G 2 P 2

OB Index: G 2 P 2 (2002) OB Index: G 2 P 2 (2002) Previous Pregnancy: Previous Pregnancy: Date: 2007 Sex: Male BW: 2.7 kg Place: Perpetual Help Hospital Delivery Type: 1 o Low-segment C.S. AOG: Full Term Complications: Cephalopelvic Disroportion

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

Onset of Uterine Activity: Spontaneous Onset of Uterine Activity: Spontaneous Intensity of Contractions: Moderate Intensity of Contractions: Moderate Membrane Status: Intact Membrane Status: Intact Analgesia: None Analgesia: None

Mode: Abdominal Mode: Abdominal Amniotic Fluid: Slightly Meconium Stained Amniotic Fluid: Slightly Meconium Stained Analgesia: Subarachnoid Block Analgesia: Subarachnoid Block

APGAR Score: 5, 9 APGAR Score: 5, 9 Resuscitation: Resuscitation:  Supplementary O 2 10 LPM via hood  Positive Pressure-Ventilation

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

GENERAL APPEARANCE: vigorously crying with active motor activity VITAL SIGNS: T: 36.6 o CHR: 130 bpm RR: 50 cpm Wt: 2600 gLt: 49 cmHC: 32.5 cm CC: 31 cmAC: 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 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 & 1 vein BACK: lanugo with bald areas, (-) dimpling, straight spine

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

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

(+) history of meconium staining baby received non-vigorous, HR 60s, poor muscle tone, with no response (+) tachypnea (+) grunting (+) retractions

CONSIDERATIONS: (+) tachypnea (+) grunting (+) retractions RULED-OUT: rare in term neonates mother not GDM worsens / peaks at hours CXR findings:ground glass appearance, air bronchogram, diffuse reticulogranular infiltrates

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

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

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

Ordered CBC with PC, Blood typing, ABG, Na, K, Cl, Ca, CXR APL, Blood Culture and Sensitivity Venoclysis started with D 10 W 9cc/hr NPO, Hgt q8 O2 support at 10 lpm/hood

ARTERIAL BLOOD GAS %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 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D 5 W 23.1cc) UVC inserted

Due to persistent desaturation (O 2 sats 80’s), patient intubated with MV settings 100%, 18/3, RR 60 LT 0.4 O 2 sats improved to % ABGs ordered D 10 W increased to run for 10 cc/hour STAT NaHCO 3 5 meqs given ABGs ordered

ARTERIAL BLOOD GAS after intubation %

ARTERIAL BLOOD GAS after NaHCO

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 D 10 IMB Ca 10cc/hr

CBC AND BLOOD TYPE BLOOD TYPEB positive HGB129 HCT0.386 WBC5.56 SEGMENTERS0.697 LYMPHOCYTES0.18 MONOCYTES0.101 EOSINOPHILS0.016 PLATELET227

ARTERIAL BLOOD GAS

Decrease RR to 50 then decrease by 2 q2 until 30 Decrease FiO 2 by 5 q2 until 60%

MV setting at 80%, 18/3, 44, 0.4 ABGs ordered Once FiO 2 60%, may start feeding with 5cc EBM q3/OGT with SAP

ELECTROLYTES Na143 K3.9 Cl108 Ca1.6

Start feeding 5cc EBM as ordered, if tolerated 3x, start increments: increase 5cc every feeding until 30cc MV setting: 60% 18/ Wean FiO 2 by 5 q2 til 21% Wean RR by 2 q2 til 10 Extract ABGs at RR=10

Prepare for extubation Prepare O 2 hood FiO 2 30% MV settings at 21%, 18/3, 14, 0.4 Revise inotropes: Dopamine 0.5cc + D 5 W 23.5 cc to run at 1cc/hour then consume then discontinue

S/P Extubation Placed on O2 hood FiO 2 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

For CPT with proper shields Dopamine discontinued NCPAP 30% PEEP 5 ABGs Noted vomiting with feeding; abdomen soft but distended Feeding decreased to 30cc

ARTERIAL BLOOD GAS

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

TOTAL BILI., DIRECT BILI., INDIRECT BILIRUBIN TB15.9 DB0 IB15.9

13cc of feeding residual noted; no abdominal distention Feeding deferred Wean FiO 2 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

ARTERIAL BLOOD GAS

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

For repeat CBC with PC, blood CS, eletrolytes To start Ceftazidime (50mkd) 130mg IV q12h NPO IVF revised to: D 10 1MB Ca 13cc/hr Please put patient on right side up

CHEST X-RAY Meconium Pneumonitis with atelectasis on the right