Legaspi, Luis Ontok, Abdul-Aziz Payumo, Edelissa Pelayo, May Angela Rodriguez, Melissa Samson, Edgardo

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

HR 60’s, limp, acrocyanotic, with no response HR 50’s, some flexion, acrocyanotic, (+) grimace HR 100’s, some flexion, acrocyanotic, (+) grunting HR 130’s, active, acrocyanotic, (+) crying, RR (+) Grunting, (+) retractions NICU 3 Thermoregulation, Suctioning, Tactile stimulation Thermoregulation, Suctioning, Tactile stimulation, PPV Thermoregulation, Given blow by O 2, Stimulation Weaned off from O 2 Placed on O2 support via 10 lpm

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: limp, in respiratory distress 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

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 RULE-IN RULE-OUT Hyaline Membrane Disease (+) Grunting (+) Retractions Rare in term neonates Mother not GDM Worsens/peaks at 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 0 2 With rapid recovery in 3 days PE: lungs clear w/o rales or rhonchi Benign, self-limited course

DIFFERENTIAL RULE-IN RULE-OUT Neonatal Pneumonia (+) Grunting (+) Retractions 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

DIFFERENTIAL RULE-IN RULE-OUT Neonatal Sepsis (+) Grunting (+) Retractions Cannot be fully ruled out

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

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 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 D 10 W 9cc/hr NPO, Hgt q8 O 2 support at 10 lpm/hood Why?

COMPONENT05/07/09NORMAL VALUES WBC – 30.0 RBC – 6.0 HGB HCT – Platelet – 450 Neutrophil – Lymphocyte – Monocyte – Eosinophil – Basophils – COMPLETE BLOOD COUNT

ARTERIAL BLOOD GAS pH  pCO  pO  HCO  BEb-8.2 O 2 sat91.40% COMBINED METABOLIC AND RESPIRATORY ACIDOSIS

NICU

S: (+) hypotension, (-) hypothermia, (-) dyspnea O:pink all over, some flexion of extremities, weak cry RR:24 HR:132 BP:30-40 T:36.6 o O 2 :85-95% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) grunting, clear breath sounds adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good 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

P:  Given total of 50 cc PNSS IV bolus  Started on 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D 5 W 23.1cc)  UVC inserted

S: (+) persistent desaturation, (-) tachycardia, (+) dyspnea O:acrocyanotic, some flexion of extremities, weak cry RR:72 HR:144 BP:40-50 T:36.7 o O 2 :80% (+) alar flaring, (-) circumoral cyanosis equal chest expansion, (+) ICS retractions, (+) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good 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

P:  Intubated with MV settings: FiO 2 100%, 18/3, RR 60 LT 0.4  D 10 W increased to run for 10 cc/hour

ARTERIAL BLOOD GAS (post-intubation) pH  pCO pO HCO  BEb-8.5 O 2 sat99.50% UNCOMPENSATED METABOLIC ACIDOSIS (NaHCO 3 5 meqs)

ARTERIAL BLOOD GAS (post-NaHCO 3 ) pH7.407 pCO  pO HCO  BEb-5 O 2 sat99.30% COMPENSATED REPIRATORY ALKALOSIS

S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever, (+) BM x1, (+) UO x2, (-) jaundice O:pink all over, good muscle tone, awake RR:56 HR:128 T:36.7 o O 2 :99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses

CHEST X-RAY CHEMICAL PENUMONITIS

BLOOD CHEMISTRY CALCIUM 1.60 mmol/L  (2.12 – 2.52) SODIUM143 mmol/L(136 – 145) POTASSIUM3.9 mmol/L(3.50 – 5.10) CHLORIDE108 mmol/L(98 – 107) HYPOCALCEMIA

ARTERIAL BLOOD GAS pH7.468 pCO  pO HCO  BEb-9.8 O 2 sat99.80% COMPENSATED RESPIRATORY ALKALOSIS

A: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 D 10 IMB Ca 10cc/hr  Decreased RR to 50 then by 2 every 2 hrs until 30  Decreased FiO2 by 5 every 2 hours until 60% Why?

S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever, (+) BM x2, (+) UO x3, (-) jaundice O:pink all over, good muscle tone, asleep RR:44 HR:136 T:37.2 o O 2 :99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good capillary refill, strong pulses

ARTERIAL BLOOD GAS pH7.360 pCO pO HCO BEb-5.1 O 2 sat99.20% NORMAL ARTERIAL BLOOG GAS (????)

A: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 FiO 2 60%, may start feeding with 5cc EBM every 3 hours per with strict aspiration precaution

P:  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 every 2 hours until 21%  Wean RR by 2 every 2 hours until 10  Extract ABGs at RR=10

S: (-) tachycardia, (-) dyspnea, (-) fever, (-) jaundice O:pink all over, good muscle tone, asleep RR:44 HR:136 T:37.2 o O 2 :99% (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good 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

ARTERIAL BLOOD GAS (post-extubation) pH7.324 pCO pO HCO BEb-4.7 O 2 sat95.60% ??????????????

P:  Extubated  Placed on O 2 hood FiO 2 30%  Revised inotropes: Dopamine 0.5cc + D 5 W 23.5 cc to run at 1cc/hour, then consume, then discontinue  Racemic epinephrine nebulization started, to continue 2 more doses 15 minutes apart

S: (-) fever, (+) jaundice, (+) coffe-ground material/ogt O:pink all over, good muscle tone, asleep RR:48 HR:152 T:36.7 o (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur distended, soft, (-) masses good 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

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

S: (-) dyspnea, (-) fever, (+) jaundice, (+) vomiting O:pink all over, good muscle tone, asleep RR:44 HR:148 T:37.0 o (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good 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; Hyperbilirubinemia no set-up

TOTAL, DIRECT, INDIRECT BIL. TB16.1 mg/dl(10.00 – ) DB0 mg/dl(0.00 – 10.00) IB16.1 mg/dl(10.00 – ) NORMAL

P:  Maintained on phototherapy  NPO  Wean FiO 2 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?

S: (-) dyspnea, (-) fever, (+) jaundice, (+) vomiting O:pink all over, good muscle tone, asleep RR:47 HR:152 T:36.8 o (-) alar flaring, (-) circumoral cyanosis equal chest expansion, (-) ICS retractions, (-) grunting adynamic precordium, (-) tachycardia, (-) murmur globular, soft, (-) masses good 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; Hyperbilirubinemia no set-up

ARTERIAL BLOOD GAS pH7.329 pCO pO HCO BEb-3.5 O 2 sat92.40% ??????????????

CHEST X-RAY ATELECTASIS, RIGHT UPPER LOBE ATELECTASIS/CONSOLIDATION, MEDIAL SEGMENT OF RLL

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

COMPONENT05/07/0905/12/09NORMAL VALUES WBC – 30.0 RBC – 6.0 HGB HCT – Platelet – 450 Neutrophil – Lymphocyte – Monocyte – Eosinophil – Basophils – COMPLETE BLOOD COUNT

BLOOD CHEMISTRY TEST5/9/095/12/09Normal Values CALCIUM1.60 mmol/L1.92 mmol/L(2.12 – 2.52) SODIUM143 mmol/L140 mmol/L(136 – 145) POTASSIUM3.9 mmol/L4.3 mmol/L(3.50 – 5.10) CHLORIDE108 mmol/L106 mmol/L(98 – 107)

TOTAL, DIRECT, INDIRECT BIL. TEST5/9/095/12/09Normal Values TB16.1 mg/dl14.6 mg/dl(10.00 – ) DB0 mg/dl0.0 mg/dl(0.00 – 10.00) IB16.1 mg/dl14.6 mg/dl(10.00 – )

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.

3 major constituents of meconium: 1.Intestinal secretions 2.Mucosal cells 3.Solid elements of swallowed amniotic fluid are the 3 major solid constituents of meconium. Water - major liquid constituent, (85-95%)

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

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

Fetal hypoxic stress (head or cord compression) ↓ Vagal stimulation ↓ Mature gastrointestinal tract ↓ Peristalsis ↓ Rectal sphincter relaxation ↓ Meconium passage

Meconium + amniotic fluid ↓ 1. perinatal bacterial infection 2. erythema toxicum 3. stained amniotic fluid aspiration

Aspiration induces hypoxia via 3 major pulmonary effects: 1. airway obstruction 2. surfactant dysfunction 3. chemical pneumonitis

1. Airway obstruction Complete obstruction - atelectasis Partial obstruction - ball-valve effect

2. 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

3. 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

Meconium 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

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

Yellow-green staining Fingernails Umbilical cord Skin

Acid-base status Metabolic acidosis from perinatal stress Respiratory acidosis from parenchymal disease and persistent pulmonary hypertension of the newborn (PPHN).

Serum 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

CBC 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

Air trapping and hyperexpansion from airway obstruction.

Acute atelectasis

Pneumomedia- stinum from gas trapping and air leak

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

Diffuse chemical pneumonitis from constituents of meconium

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

Meconium Aspiration ↓ Intubation ↓ Suctioning (Tracheal suctioning)

No 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

NOT 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

VIGOROUS (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

In either case, The remainder of the initial resuscitation steps should ensue and include: drying, stimulating, repositioning, and oxygen administration as necessary

 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

1. Chronic lung disease 2. Infections

 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

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

1.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

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

Jaundice appearing after the 3 rd day and within the 1 st week suggests bacterial sepsis or urinary tract infection Other causes: syphilis, toxoplasmosis, CMV, enterovirus

Regardless of the cause, goal of therapy is to prevent indirect-reacting bilirubin related neurotoxicity Tx: phototherapy and exchange therapy

End Thank you!