A mortality review of a case in NICU

1. MORTALITY REVIEW

2. Patient Details
• Baby Umair
• Day 35 of life
• DOB: 3/7/23
• BW: 2.58kg
• G6PD: Normal
u/l
• 1/ Late prem at 36 weeks 1 day via SVD
• 2/ infant of mother with GDM
• 3/ congenital heart disease -VSD
• Admission : 20/7/23
• Death: 6/8/23

3. History of Admission
1st admission
• At Birth
• 3/7/2023 –4/7/2023
• for infant of mother with GDM on
OHA
• DXT monitored in ward stable
• Discharged well on 4/7/2023
2nd admission
• Day 4 of life for NNJ
• 5/7/2023 – 6/7/2023
• only required 1 day of single
phototheraphy
•noted soft systolic murmur
•Bedside ECHO -small VSD
•referred peads cardio
3rd and 4th admission
• rebound NNJ
• day 5 OL (7/7/2023-8/7/2023)
• D7 OL (10/7/2023-11/7/2023)
• only required 1 day of single
phototheraphy

4. History of Presenting Illness
• day 18 of life (20/7/2023) for significant weight loss of 15%
• 2.58kg --> 2.19kg
• Mother complained of loose stool 2/7
• >5 episode per day
• 3-4 times changing of diapers - light weight
• right side eye discharge 2/7
further hx
• on breast feeding and Formula milk (lactogen)
• Formula milk tolerated only for 20cc even though 60cc was prepared
• Usually feeding on night, less tolerated on the day
• No vomiting, no choking, no sweating upon feeding
• Does not look lethargic/long sleeping post feeding

5. Physical Examination
• alert , lethargic looking , pink
• sunken eyes ,weak pulse volume
• anterior fontenelle mildly sunken, CRT <2sec, not tachypnoeic
• intermittent hiccup with suprasternal recession
v/s
• BP 78/31 (MAP of 46)
• DXT 2.7
• lung clear
• cvs soft systolic murmur
• abdomen soft , not distended

6. Blood Investigation
• VBG : PH 7.17/ hco3 13.1/lac 4.3
• FBC: HB 12.0/ WBC 10.9/PLT 466
• RP: U 3.2/NA 145/ CHL 121/K 5.0/ CREAT 35
• Stool for Rotavirus : negative

7. Imaging

8. Diagnosis
1. Late prem 36 weeks 1 day with significant weight loss
2. enterocolitis with metabolic acidosis complicated with lactose
intolerance

9. Management
• 10cc/kg of bolus normal saline given
• started on full IVD maintainence of 150cc/kg/day
• NPO2
antibiotic
• -IV Ampicilin
• -IV Gentamicin
• -IV Flagyl
• Gentamicin eye drop

10. Day of Admission Progres Blood Ix Management
Day 2
(21/7/23)
• high anion gap metabolic acidosis with high
lactate and hyperchloremia (anion gap 21)
• hypomagnesemia and hypokalemia
NA 125
K 2.2
CL 99
Mg 0.62
• Transfer to NICU
• IVD 10% correction
• correction for hypomagnesemia
and hypokalemia
Day 4
(23/7/23)
• restarted on 10cc/3 hourly feeding
• child had watery stool up to 6 times/day
• eye discharged resolved
Eye swab C+S -
ESBL E coli
• changed to lactose free
formulae
Day 6
(25/7/23)
• less active with mild pallor and mildly
tachypneic
HB 8.5
Na 125
• escalated to IV Tazocin 190mg
QID
Day 7
(26/7/23)
• bedside ECHO noted -slightly dilated LA /LV
with PMVSDPMVSD in failure
• packed cell transfusion of
20cc/kg with IV Frusemide 2mg
in between transfusion
• planned for antifailures later
Day 9
(28/7/23)
• frequent diarrhea total 8 episodes
• weight loss from 2.3kg to 1.9kg
• noted to be mildly tachypneic with
subcostal recession
HB 14.1
WBC 11.1
PLT 212
U 3.9/NA 139/K
4.3/CREAT 44
• 10cc/kg Normal saline bolus
• full maintainence IVD and 10%
correction over 24 hours
• escalated to CPAP

12. Revised Impression
1. Late prem 36 weeks 1 day with significant weight loss
2. VSD in failure
3. enterocolitis with metabolic acidosis complicated with lactose
intolerance, hypokalaemia, hypomagnesaemia and hyponatraemia
4. severe anaemia secondary to enterocolitis

13. Day of Admission Progress Blood ix Management
Day 10
(29/7/23)
• child hydration improved
• no sunken eye and normotensive frontanelle
• restarted on trophic feeding
3cc/3hourly -stop d/t
persistent diarrhea.
Day 14
(2/8/23)
• diarrhea was less watery
• noted soft inspiratory stridor
• completed IV Tazocin for 5 days
hb 9.2 • transfused with 20cc/kg of
pack cell with IV frusemide
1m in between transfusion.
• refer ENT
Day 17
(5/8/23)
• tolerating 9cc/hourly 3 hourly and rest for 1 hour
• still having diarrhea but more formed stool and
small amount
• CPAP was off and changed to
headbox 10L/min.
Day 18
(6/8/23)
• noted that child had abdominal distension
• but no discolouration, not tenses
• child was still passing out stool
• However child collapsed at 6am

14. Day 18 of admission (20/7/23)
• immediately intubated with ETT size 3.5mm anchored at 8.5cm
• Intubation was successful however noted pooling of blood in the oral cavity
• CPR was initiated at 0620am
• Child ROSC after 18 minutes of CPR.
• Post ROSC, child was transfer to acute bay
• child had poor perfusion (CRT >2s, and poor pulse volume)
• Blood was pooling over the ETT during bagging
• hence DIVC regimen was requested 10cc/kg of FPP, platelet and
cryoprecipitate each.
• bedside ECHO was done, reveals no cardiac tamponade, but poor contratality
• he was started on 10mcg/kg/min of dobutamine and IV Meropenem 40mg/kg
dose was given STAT
• His SPO2 was unrecordable throughout even, HR ranging from 120-140bpm

15. • Child subsequently asystole again at 0705am CPR commenced
immediately. Total CPR for 40 minutes but unable to revieve the child.
Pupil fixed and dilated
• Pronouced death at 0740am 6/8/2023
• Cause of death, septic shock