This document summarizes the mortality meeting discussion of a preterm infant born at 25 weeks gestation who was brought to the hospital in a gasping condition. The infant was intubated and started on IV fluids and antibiotics. Surfactant was administered and chest x-ray showed signs of RDS. The infant was put on ventilatory support but developed metabolic acidosis, skin mottling, and respiratory distress. Inotropic support was started but the infant suffered cardiac arrest and died despite resuscitation efforts.

1. MORTALITY MEETING 29 APRIL 2016

2. b/o jamuna nb /f/740gm CRN 201603276406
Tob 4;10pm dob 16/3/16
•
•NVD ,CIAB?,AUTO RICKSHAW DELIVERY,
• POG 25WEEK
G2P1L1
•RECEIVE IN GASPING
CONDITIONINTUBATED WITH ET TUBE NO
2 (BETTER TO PUT 2.5

3. ET tube sizes
Weight GA(weeks) Tube size(mm)
(internal diameter)
Below 1 kg 28 2.5
1-2 kg 28-34 3.0
2-3 kg 34-38 3.5
>3kg >38 3.5- 4.00
3

4.  STARDED IV FLUID 40ML 12 HRLY 5%
D(>100ML/KG/DAY) BETTER TO START80-90
ML/KG/DAY BCZ PT SHOULD GIVEN RESTRICTED
FLUID BCZ OVER FLUID MAY LED TO OPENING OF
PDA,NEC,BROCHOPULMONARY DYSPLASIA
 These PT have large insensible loss of fluid ,immature
skin barrier use of transparent plastic barrier
,application of coconut oil, use of double wall
incubator

5.  Monitor temp
 Inj vit K
 Shifted to nursery
 SURFACTENT
 NEW BALLARD SCORING
 RISK FACTOR IN MOTHER
 SEPTIC SCREEN
 CXR

6. RISK FACTOR FOR EONS
 1. Low birth weight (<2500 grams) or prematurity
 2. Febrile illness in the mother with evidence of bacterial infection within 2
weeks prior to
 delivery.
 3. Foul smelling and/or meconium stained liquor.
 4. Rupture of membranes >24 hours.
 5. Single unclean or > 3 sterile vaginal examination(s) during labor
 6. Prolonged labor (sum of 1st and 2nd stage of labor > 24 hrs)
 7. Perinatal asphyxia (Apgar score <4 at 1 minute)
 Presence of foul smelling liquor or three of the above mentioned risk factors
warrant initiation of
 antibiotic treatment. Infants with two risk factors should be investigated and
then treated accordingly
 Source:aiims protocol of neonatology

7. surfactant
 Natural
1. Minced lung extract a)surfactant TA(SURFACTEN)
b)beratant(SURVANTA)
c)poratent alfa (curosurf)
1. Lung lavage extract
2. Amniotic fluid extract
 Synthetic 0ld synthetic (Protein free)eg exocurf
new synthetic (protein analogue)eg
surfaxin

8. Indication of SRT
 RDS
 OTHER WHERE SURFACTANT IS INACTIVATED
SUCH AS MAS,PNEUMONIA,PULMONARY
HAEMOORRHAE,CDH,ARDS
 IN RDS IT IS GIVEN AS PROPHYLACTIC OR AS
RESCUE THERAPY

10.  PROPHYLACTICALLY : IN DELIVERY ROOM
WITHIN 15 MIN
 EARLY RESCUE ;WITHIN 2 HR IF RDS DEVELOP
 LATE RESCUE: >2 HR DONE IN OUTDOOR PT
REFFERED FROM OUTSIDE

11. DOSE
 SURVANTA (DOSE phospho lipid )4ml/kg
100mg/kg
 CUROSURF (dose phospholipid)2.5ML/KG
200MG/KG
 NEOSURF (dose phospholipid)5ML/KG 135MG/KG

12. PROCEDURE
 EXPERIENCE PHYSICIAN(who can anticipate
,recognize ,t/t complication of surfactant)
 WARM DO NOT SHAKEINTUBATE ASSES
BREATH SOUND-CONNECT TO PULSE
OXIMETER->INSERT FEEDING TUBE SUCH THAT
TIP PROJECT BEYOND ET TUBE->surfactant given as
bolus in four aliquots -> connect the infant to
ventilator, T piece, resuscitation bag till saturation and
heart rate stabilizes before administering next aliquot
 No position change is required
 Avoid suction at least 2 hr after administration

13. Septic screen
the sepsis screen consists of 5 items: C-reactive protein
(CRP), absolute
neutrophil count (ANC), immature to total neutrophil ratio
(ITR) and micro-erythrocyte
sedimentation rate (μ-ESR).TLC
• CRP: Quantitative CRP assayed by nephelometry is superior
to CRP by ELISA and semiquantitative
CRP by a latex agglutination kit. Cut-off value for
quantitative assay is 10 mg/L.
• ANC: It must be low count as per Manroe’s charts or
Mouzinho’s chart, depending on whether it is a term
baby or a preterm baby respectively .

14. • Immature /total neutrophil ≥0.2
• μ-ESR. Value ≥ 15mm in first hrs
TLC (TOTAL LEUKOCYTE COUNT) <5000/MM₃
Source:aiims protocol of neonatology

15. NEW BALLARD SCORING

16. Neonatal Gestational Age
Physical Maturity

17. Neonatal Gestational Age
Neuromuscular Assessment

18. SCORE WEEKS
-10 20 50 44
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42

19. CXR

20. RDS
Low volume lung
Fine reticulogranular pattern
Ground glass apperence
Air bronchogram
White out lung

21. RUL pneumonia

22. Meconium Aspiration Syndrome
Hyper inflated lung,
Coarse nodular fluffy
opacity
Patchy atelactesis
Area of over inflation

23.  BABY PUT ON VENTILLATORY SUPPORT-
>SETTING WAS
 PRVC MODE PEEP 5CM, TV 10,RATE 50,FIO2 80%
 COMMENT ON VENTILLATORY SETTING
->IN TAXIM
INJ AMIKACIN SHOULD ALSO BE STARTED
@18MG/KG/DOSE EVERY 48 HR DOSE IS FOR
<29WEEK

24.  VBG
Ph - 7.235 (acidosis)
pCO2 - 29.5 mm Hg, pO2 - 30.1 mm Hg
HCO3 - 12.2
->METABOLIC ACIDOSIS->I/V NS 7.5CC SLOWLY OVER ½
HR --.>IV AMIKACIN STARTED (DOSE IS NOT AS PER
AIIMS PROTOCOL @18 MG/KG/DOSE EVERY 48 HRLY
SAME CONDITION CONTINUE
BUT NO MONITORING OF SPO2 BCZ FIO2 increase to
90%, other setting same

25.  Skin mottling is there I/V BOLUS 10ML/KG +DOPAMINE
@10MICROGRAM/KG/MIN,ET ALSO CHANGE
 NNR,TONE,ACTIVITY-----NIL
 RD STARTED RR 58,RETRACTION PRESENT,CFT
4SEC,SPO2 88% with fio2 100%
 SIMV MODE STARTED PEEP 5,TV 10,FIO2 100%
 DOWNY YA SILWERMAN SCORING SHOULD BE DONE
FOR ASSESSMENT OF RESPIRATORY DISTRESS

26. SILVERMAN- ANDERSON
RETRACTION SCORE FOR
PRETERMS

27.  Started adrenaline infusion @.2 microgram /kg/hr
 7am baby develop cardiac arrest chest
compression inj adr @.1ml/kg(1:10,000) iv twice
 But second dose should be .2ml/kg
 Cpr continue (TIME NOT MENTION)
 7:25AM DECLARED DEATH

28.  THANK YOU