1. Severe Respiratory Distress Syndrome Ma. Victoria Carmela B. de la Paz

2. General Data Baby Boy G.O. Delivered via STAT Primary Cesarean Section due to Prolonged Deceleration 30 year old G1P1 (0101) at 26 1/7 weeks Age of gestation, MT 28 weeks, SGA

3. General Data Baby Boy G.O. Delivered via STAT Primary Cesarean Section due to Chronic Hypertension with superimposed pre- eclampsia, non-reassuring fetal status (absent end diastolic flow, intrauterine growth restriction), prolonged deceleration 30 year old G1P1 (0101) at 26 1/7 weeks Age of gestation, MT 28 weeks, SGA BW 580g BL 30cm HC 31 ½ cm CC 19 ½ cm AC 16cm AS 9,9

4. Maternal History Superimposed pre-eclampsia at 26 weeks age of gestation – Maintained on Methyldopa and Amlodipine Given: – Hydralazine 5mg/IV x 3 doses for BP management – MgSO4 3g/IV as neuro protectant – Betamethasone 12mg/IM for fetal lung maturity – Methyldopa 250mg 2 tablets for BP control

5. Past Maternal History Hypertension (2014) on Amlodipine S/P Polypectomy (2015)

6. Family History Diabetes Stoke Hypertension

7. Personal/Social History Call center agent Denies smoking/alcohol intake Coffee drinker (2 cups a days)

8. Upon Delivery Drying and stimulation was done 1 st minute APGAR Pink, Good cry and activity, HR 110 bpm Suctioning was done and free flow oxygen was given 2 nd minute APGAR HR 120bpm, free flow oxygen was continued Placed in pre-warmed ziplock for thermoregulation and hooked to pulse oximeter 5 th minute APGAR Transferred to NICU Level 3

9. Course at the NICU Subjective Good cry and activity Urine output Objective Pink Soft ear pinna with some recoil No cleft lip or palate Good cardiac tone, HR 130-140bpm Good air entry, no retractions Soft abdomen Full pulses Assessment Preterm baby Boy, SGA Plan Place in pre- warmed insolate Hook to Oxygen support at 1LPM via nasal cannula Insert UVC Septic work up BCS, CBC, BT and CXR Antibiotics Ampicillin 103mkday Cefotaxime 103mkday IVF: D5W (TFR 80)

10. Laboratories HgbHctWBCBandsNLMEPlt 6/28127393.8015794217712nRBC/100WBC Blood type: B+ Blood culture: No growth

11. CXR s/p UVC insertion

13. 4 th hour of life Subjective Increased work of breathing Good cry and activity Meconium passage Objective Pink Fair air entry, with suprasternal and subcostal retractions Good cardiac tone, no murmur Soft abdomen, non-distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome R/O Sepsis Plan Prepare for intubated and surfactant therapy Hook to Mechanical ventilator: FiO2 30 RR 40 PIP 15/4 FR 10 IT 0.4

14. 8 th hour of life Subjective No respiratory distress No desaturations Objective Pink Good air entry, with suprasternal and subcostal retractions, Better chest rise Good cardiac tone, no murmur Soft abdomen, non-distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Plan For repeat CXR to check for respiratory distress deficiency For EG7 to get blood gas values and HGT Cranial Ultrasound in the morning

15. Laboratories pHpCO2pO2HCO3BEsO2 6/28 6pm 7.32432922.1-450 NaKIcal 6/28 6pm1334.61.21 HgbHctWBCBandsNLMEPlt 6/28127393.8015794217712nRBC/100WBC 6/28 EG7 6pm 15646 Hgt = 124mg/dL

16. CXR s/p Surfactant therapy

17. 13 th hour of life Subjective NPO Intubated No desaturations noted UO = 8cc/kg/8 hours Objective Pink Good air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non-distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Plan For cranial ultrasound For repeat blood gas (EG7)

18. 19 th hour of life Subjective NPO Intubated No desaturations noted UO = 6.6cc/kg/19 hours Objective Pink Good air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non-distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Plan For cranial ultrasound Start TPN D5 AA 6% (2g/kg) Na (2meq/kg) K (1meq/kg) Ca gluc (200mg/kg) Hgt Adjust the ff MV settings: FiO2 30 RR 30

19. Laboratories pHpCO2pO2HCO3BEsO2 6/28 6pm 7.32432922.1-450 6/29 6am 7.2746.73421.6-557 NaKIcal 6/28 6pm1334.61.21 6/29 6am1344.71.14 HgbHctWBCBandsNLMEPlt 6/28127393.8015794217712nRBC/100WBC 6/28 EG7 6pm 15646 6/29 EG7 6am 16047 Hgt = 47mg/dL

20. 19 th hour of life Subjective Hgt 47mg/dL Active No sigsn of jitteriness Objective Jaundiced Good air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non- distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Hyperbilirubinemia Plan Push 2cc/Kg D10W Repeat Hgt 1 hour after

21. 26 th hour of life Subjective Sudden onset of desaturations (95%  70%) with cyanosis Bradycardic episode (HR 70-80bpm) Objective Jaundiced suprasternal and subcostal retractions, poor chest rise with fair air entry Bradycardic, no murmur Soft abdomen, non-distended Assessment T/c Pneumothorax vs obstructed ET Sepsis HMD Plan Needling was done – no bubbling Re-intubation Epinephrine via UVC

23. 28 th hour of life Subjective S/P re-intubation S/P surfactant therapy Oxygen sats: 84- 86% Objective Jaundiced Better air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non- distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Hyperbilirubinemia t/c Pneumothorax Plan Adjust the ff MV settings: FiO2 100 RR 75 PIP 32/4 IT 0.4 FR 12 Vitamin K 0.05ml IM Discontinue phototherapy

24. 31 st hour of life Subjective Stable vitals Objective Jaundiced Better air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non- distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Hyperbilirubinemia t/c Pneumothorax Plan Dopamine drip started For EG7

25. Laboratories pHpCO2pO2HCO3BEsO2 6/28 6pm7.32432922.1-450 6/29 6am7.2746.73421.6-557 6/29 8pm7.2150.43120.0-846 NaKIcal 6/28 6pm1334.61.21 6/29 6am1344.71.14 6/29 8pm1396.51.26 HgbHctWBCBandsNLMEPlt 6/28127393.8015794217712nRBC/100WBC 6/28 EG7 6pm 15646 6/29 EG7 6am 16047 6/29 EG7 8pm 15044

26. 33 rd hour of life Subjective Intubated No jitteriness No desaturations Objective Jaundiced, mottled Good air entry, with suprasternal and subcostal retractions, Visible chest rise Good cardiac tone, no murmur Soft abdomen, non- distended Assessment Preterm baby Boy, SGA Respiratory Distress Syndrome s/p surfactant therapy R/O Sepsis Hyperbilirubinemia t/c Pneumothorax Plan Adjust the ff MV settings: Shift to AC mode FiO2 100 RR 86

27. CXR

28. Time line of Events 11:50pm – desaturations (80%) improved with bagmask ventilation. HR >100bpm with secretions; good air entry, equal chest rise – Continue suctioning – Continue bag-tube ventilation 12:20am – No desaturations, O2 sats 88-89% HR 130; good air entry – Hook back to mechanical ventilator 12:30am – desaturations (70%) improved with bag-tube ventilation; HR 120-130 – Continue bag-tube ventilation

29. 12:50am – desaturations despite bag-tube ventilation (70%) improved but not sustained. – Continue bag-tube ventilation 1:05am – HR 70-80; Os sat 60%; no spontaneous breathing, cyanosis – Chest compressions – Epinephrine 0.05ml (0.01mkdose) – Continue bag-tube ventilation

30. 1:10am – HR 60bpm; O2 sat 60%, no spontaneous breathing – Epinephrine 0.05ml (0.01mkdose) – Chest compressions 1:13am – HR 50bpm O2 sat 50% – Epinephrine 0.05ml (0.01mkdose) 1:16am – HR 40-50bpm; O2 sat 40-50% – Epinephrine 0.05ml (0.01mkdose) 1:21am – HR 30bpm; o2 sat 4-=50% – Epinephrine 0.05ml (0.01mkdose) 1:25am – HR 30bpm; o2 sat 20%; cyanosis – Epinephrine 0.05ml (0.01mkdose)

31. 1:33am – HR 30-40bpm; o2 sats 20-30%; marked pallor, AF full, occasional gasping, cold extremities, (-) pulses – Epinephrine drip 0.2mcg/kg/min) – Parents updated 1:43am – HR 114; o2 sats 96% – NaHCO3 1 meq + 1ml to make 2ml (1.7meq/kg) for acidosis (2 doses) – Transfuse 30ml of B+ pRBC un-crossmatched (parents refused)

32. 2:30am – continuous bagging; HR 107-109; o2 sats 60-79 – Parents request DNR 2:45am – patient expired

33. PRETERM 26 1/7 WEEKS BY OB SCORE, 28 WEEKS BY MT, SGA, SEVERE RDS S/P SURFACTANT THERAPY; SEPSIS UNSPECIFIED; RESPIRATORY FAILURE PROBABLY INTRAVENTRICULAR HEMORRHAGE Final diagnosis