1. NICU Case Discussion: Baby Calingasan Pelayo-Samson

2. GENERAL INFORMATION Baby Boy of J. C. Patient is born full term 37 weeks by PA 2600 grams AGA cephalic presentation delivered by repeat LSCS to a 23 year old G2P1(1001) mother. Mother had a stable primary antenatal condition, had 2 pre-natal check-up c/o PGH. No maternal illnesses, no vices, no medications during pregnancy.

3. PHYSICAL EXAMINATION

5. DIFFERENTIALS DifferentialRule-inRule-out Hyaline Membrane Disease(+)tachypnea (+) grunting (+)retractions -rare in term neonates -mother not GDM -worsens / peaks at 48-36 hours -CXR findings:ground glass appearance, air bronchogram, diffuse reticulogranular infiltrates Transient Tachypnea of the Newborn -usually follows uneventful normal FT SVD or cesarean section -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 CXR: prominent pulmonary vascular markings (Sunburst pattern), overaeration, flat diaphragm -benign, self-limited course

6. Neonatal Pneumonia(+)tachypnea (+) grunting (+)retractions (+) cyanosis Pre-natal history suggests infection -usually predisposed by pre- mature labor, PROM, increased IE -CBC usually: neutropenia, leukocytosis -cannot be fully ruled-out Meconium Aspiration Syndrome (+) history of meconium staining -baby received non- vigorous, HR 60s, poor muscle tone, with no response (+)tachypnea (+) grunting (+)retractions -cannot be fully ruled-out

7. LABS

8. DIAGNOSIS Full term 37 weeks by PA 2600 grams AGA cephalic presentation delivered by repeat LSCS, AS 9,9 Meconium Pneumonitis Hyperbilirubinemia w/o set-up r/o Nosocomial sepsis

9. COURSE IN THE WARDS Born at the 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 CS  Venoclysis started with D10W (80) @ 9cc/hr  NPO, Hgt q8  O2 support at 10 lpm/hood

10. ABGs 7.18921.4 51.2-8.2 76%91.4%

11. COURSE IN THE WARDS 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

12. COURSE IN THE WARDS  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

13. ABGs after intubation 7.28318.5 38.8-6.9 29199.9%

14. ABGs after NaHCO3 7.40717.80 28-5 14699.30

15. COURSE IN THE WARDS 1 st HD, 1 st DOL  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 D10 1MB Ca 300 @ 10cc/hr

16. CBC and Blood Type Blood TypeB positive Hgb129 Hct0.386 WBC5.56 Segmenters0.697 Lymphocytes0.18 Monocytes0.101 Eosinophils0.016 Platelet227

17. ABGs 7.46810.50 14.40-9.8 19199.80

18. COURSE IN THE WARDS  Decrease RR to 50 then decrease by 2 q2 until 30  Decrease FiO2 by 5 q2 until 60%

19. COURSE IN THE WARDS 2 nd HD, 2 nd 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

20. ELECTROLYTES Na143 K3.9 Cl108 Ca1.6

21. COURSE IN THE WARDS  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

22. COURSE IN THE WARDS 3 rd HD, 3 rd 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

23. COURSE IN THE WARDS  s/p extubation  Placed on O2 hood FiO2 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

24. COURSE IN THE WARDS  For CPT with proper shields  Dopamine discontinued  NCPAP 30% PEEP 5  ABGs  Noted vomiting with feeding; abdomen soft but distended  Feeding decreased to 30cc

25. ABGs 7.32420.3 38.6-4.7 8495.6

26. COURSE IN THE WARDS 4 th HD, 4 th DOL  Increased feeding to 35cc  TB DB IB noted  Maintain 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

27. TB DB IB TB15.9 DB0 IB15.9

28. COURSE IN THE WARDS  13cc of feeding residual noted; no abdominal distention  Feeding deferred  Wean FiO2 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

29. ABGs 7.32921.80 40.80-3.5 6892.40

30. COURSE IN THE WARDS 5 th HD, 5 th DOL  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

31. COURSE IN THE WARDS  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  CXR: meconium pneumonitis with atelectasis on the right  Please put patient on right side up

32. DISCUSSION

33. MAS

35. HYPERBILIRUBENEMIA

36. THANK YOU!