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Case prsentation from Port fouad hospital, Port said

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One of lectures given during our Port said fifth neonatology conference, 23-24 October 2014 given by dr Dr El Sayed Khalaf MD Pediatrics,Consultant Pediatric and Neonatology

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Case prsentation from Port fouad hospital, Port said

  1. 1. Port-Foad NICU Dr El Sayed Khalaf MD Pediatric Consultant Pediatric and Neonatology
  2. 2. CASE STUDY
  3. 3. Admission data • Female Preterm Baby ± 28 W GA • Accidental Vaginal delivery in Taxi. • Admitted to our NICU first day of age referred from other hospital. • Family H: brother with CP 6y, and good sister 8y. • O/E: – Very Bad general condition. – Hypothermic BP:35/25. – BW:900 gm – HC:24 cm. – Cyanosed, Weak pulses. – Chest : RD grade IV, diminished bilateral air entry. – O2 sat:70-80%
  4. 4. • Cardiac exam: – HR:160/Min, no MM or thrill. – Delayed capillary refill time • Abdominal exam: • Abd. circum: 18.5 cm • No distension – No Organomegally • Normal Umbilicus. – Neurological Exam: • Weak Reflexes, • No convulsions, lethargic, hypotonic. – Ecchymotic patches on both LL.
  5. 5. • Investigations: – CBC:HB:15gm/dl,HCT:46%, – Plt:132,WBC:10.3. – CRP: -ve – RBS: 118mg/dl – Chest X-Ray: White lungs. – ABG: • PH7.2,PCO2:57,PO2:33,Hco3:15.
  6. 6. Management • Incubator Care. • IVF: Glucose 5-7.5%, 90ml/Kg. • Inotropics: Dopamine, Dobutamine Infusion. • Prophylactic Phototherapy. • Started ET intubation immediately. • Mechanical Ventilation A/C. • NPO. • Vit K1 1mg.
  7. 7. • Surfactant adminstration (Survanta) 2.5 ml Endotracheal. • Antibiotics: Cefepim, amp-sulbactam • Ventilator Setting: – Fio2: 40%,PEEP:4,PIP:10,Rate:50/m,Ti:0.3 sec – O2 sat:92% by pulse Oxy. • Blood gases after 2 hours: – PH:7.21, PCO2:47, PO2:55, Hco3:19.
  8. 8. Day 2 • Bad general Condition. • Air entry bilateral is deminished • Convulsions started: Generalized tonic clonic, Baby desaturated, Pale with skin mottling . • No urine output. • RBS: 146 mg. • HB: 5.6 gm/dl, Plt:112, WBC:9.9, Retics: 6%. • ABG: PH 7.25, PCO2: 35, PO2: 85, Hco3: 11.6 mEq. • Vent Setting: – Fio2: 75%, PEEP: 5, PIP:19, Rate: 50/M, Ti: 0.3sec, – O2 sat:90%
  9. 9. Management • Anticonvulasnts Started: – Phenobarbitone: Loading and maintenance dose. – Phenytoin : Loading and maintenance dose. • Packed RBCs transfusion 10 ml/kg, (Twice). • Inotrops continued. • Sedation by edazolam Infusion. • TPN started: Total fluid:100ml/Kg, Pt 1gm/kg, Lipids 0.5gm/kg, MV, Glucose infusion,, GIR:5mg/kg/min. • Ca gluconate infusion:2ml/kg. • Platelets transfusion 10 ml/kg. • Vit K IV 2mg/Dose. • Furosemide 1mg/dose.
  10. 10. Day 3 - 4 • Still baby unstable, mottled, convulsions stop. • Chest: On MV, fair bilateral air entry. • Pulses average volume, 155/min. • Abdomen: soft, lax and no distension. • ABG:PH7.22,PCO2:45,PO2:98,Hco3:19 mEq. • Invest: – S Cr:0.88,Urea:72, S GPT:23,GOT:146, T Pt:4.7, Alb:3 gm. – HB:13.7, WBC:9.9, Lymp:52%.Neutro:39%, Plt:80. – CRP : -ve, TS bil:12mg, D:1mg – Bl sugar:153 – 285mg/dl after insulin infusion.
  11. 11. • Trophic feeding started 1ml/6h diluted formula or breast milk. • Platelet trasnsfusion. • Intensive phototherapy. • Still on TPN: Lipid, Pts, CHO, MV and electrolytes. • IV Ca gluc 10%. • Continuous insulin infusion with monitoring of blood glucose.
  12. 12. Day 5 • Serial measurement of serum bilirubin get low down to TSB:6.7mg/dl, D:0.90mg/dl. • Baby general condition became more stable. • Tolerate trophic feeding by NGT 1ml /4h diluted formula. • HB:13 gm/dl, Plt:156. WBC:21, CRP 6mg, S Cr:1.78, GPT:30, GOT:75, Alb:3.5 gm. • ABG:PH 7.35, PCO2:42, PO2:95, Hco3:19.6 mEq. • Vent setting: – Fio2: 21%, PEEP:5, PIP:15, Rate:40/min, Ti: 0.25 sec, O2 sat:95%
  13. 13. Day 6-11 • Abd distension, abd circumference 20 cm, bluish discoloration of abd wall. – Greenish discharge from NG tube. – Diminished intestinal sounds and not passing stools. – No organomegally, no ascites. • Attacks of desaturation and skin mottling. • Poor activity, generalized hypotonia. • No dehydration, BW:820 gm, HC:24.5cm • Pulses: very weak, BP 44/20 (M32), Delayed capillary refill time • Decrease urine output. • NEC is suspected
  14. 14. • Stop feeding. • Abdomen X-Ray: – Dilated intestinal loops, No Air under diaphragm, no air fluid levels. • Na: 135mEq, K: 3 mEq. • S Cr:1.6, Urea:123, S GPT:15, GOT:56, triglycerides 129, CRP 1.9mg, RBS ranges 128-350mg/dl. • ABG:PH: 7.36, PCO2: 44, PO2: 98, Hco3: 25 mEq. • Vent setting no critical changes. • Open NG tube, Add metronidazole infusion, Inotropics, restart insulin infusion& fluconazol infusion. • TPN: – Pt:1.5-2gm, Lipids:1-1.5gm, GIR:7-8.5mg/kg/min. – Na: 2-3meq, fat and water soluble vitamins and trace elements.
  15. 15. D 12 • Baby still has marked abd distension. • Greenish discharge from NG tube. • Suddenly the baby get severe RD, cyanosis, diminished air entry on Lt side with shift of mediastinum to the Rt side. • Baby has severe shock. • Urgent chest X-ray shows Lt sided tension pneumothorax. • ABG:PH: 7.21, PCO2:58, PO2:42, Hco3:15 mEq. • HB:12 gm/dl, RBC:4.2/CC, Plt:91. WBC:11, CRP:21mg, S GPT:32,GOT:48, • Na:122 mEq, K:3 mEq, Cr:0.8, Urea:58.
  16. 16. • Urgent chest decompression by intercostal cannula • Chest tube placement. • Inotropics. • Vent setting: – Fio2: 40%, PEEP:4, PIP:9 , Rate:60/m,Ti:0.25 sec, O2 sat:92%. • Still NPO. • Full TPN. • Na deficit is corrected. • Change antibiotics to: Targocid and Ceftazidim
  17. 17. D 15-22 • Baby general condition improved. • BW:820 gm • Air entry audible bilateral. • Less abd distension (abd circum 19.5). • Less NGT secretion and pass stool. • More active, HC 26.5, fontanell became tense, and skull sutures more wide. • CRP: -ve • HB:12 gm/dl, RBC:3.9/CC, Plt:115. WBC:16, GPT: 57, GOT:48, Na:132 mEq, K:4 mEq, Cr:0.6, Urea:58.
  18. 18. • Removal of the Chest tube. • Serial measurement of head circumference and abdominal circuference. • Still NPO, full TPN. • Phenobarbitone still. • We start IV steroids for 3 days. • Change to CPAP. • Then extubation and Nasal CPAP Fio2: 21 -30%. • With frequent chest physiotherapy • Same antibiotics. • Caffeine citrate IV. • Plan for MRI of the Brain and skull.
  19. 19. D 23-30 • Baby became more stable. BW: 840-880 gm • No convulsions or abd distension =18 cm. • Complete 14 days NPO. • No RD, Off NCPAP. • Head circumference: 27.5, Fontanelle more tense, baby more active. • HB:11gm, triglycerides:69mg/dl,Na:131,K:4 • S Cr: 0.8mg/dl. • Liver function tests: Normal values. • Neurosurgical consultation.
  20. 20. • NGT feeding started 1ml/4h breast milk. • Feeding increased gradually up to 10ml/3h full concentration premature formula and breast milk by syring pump over 1 hour. • Head box. • TPN decreased gradually. • MRI Shows: Dilated lateral and 3rd ventricles, IVH. • Phenobarbitone still continued 4mg/kg/day.
  21. 21. D 30-45 • Serial measurements of head circumference: 30cm, Fontanelles are tense, baby is active, mild hypotonia and no convulsions. • Tolerate NGT feeding and started oral suckling • Weight gain is satisfactory 1.250 kg. • Repeated neurosurgical consultation advised follow up. • Auditory function eaxam was normal. • Fundus exam not available. • CRP: -ve, HB:11gm. • Folic acid and oral phenobarbitone.
  22. 22. Up to day 56 • Baby discharged BW 1450 kg below 3rd centile for age. • Head circumference 31.5 cm, 25th centile • Full oral intake by suckling. • Neurological exam is satisfactory. • Intact reflexes. • Referred for neurosurgical consultation for follow up and fundus exam.
  23. 23. After 2months of discharge (3.15 months) • BW: 3.5 kg. 10th centile, • L: 46 cm, below 3rd centile. • Head circuference: 36 cm 25th centile. • Mild hyper-reflexia. • Oral suckling is good. • Head support and turning in bed. • Brain MRI: Mild dilatation brain ventricles.
  24. 24. Growth Curves for Prematures
  25. 25. MRI after 1 M of discharge
  26. 26. Thank You

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