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CASE DISCUSSION. Legaspi , Luis Ontok , Abdul-Aziz Payumo , Edelissa Pelayo , May Angela Rodriguez, Melissa Samson, Edgardo. HISTORY. Identifying Data. Baby Boy J.C. Full Term, 37 weeks by P.A. 2600 g, appropriate for G.A. Cephalic presentation Repeat low-segment C.S.

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Case discussion

CASE DISCUSSION

Legaspi, Luis

Ontok, Abdul-Aziz

Payumo, Edelissa

Pelayo, May Angela

Rodriguez, Melissa

Samson, Edgardo


History

HISTORY


Identifying data

Identifying Data

  • Baby Boy J.C.

  • Full Term, 37 weeks by P.A.

  • 2600 g, appropriate for G.A.

  • Cephalic presentation

  • Repeat low-segment C.S.

  • 23 year old, G2P2


History of present illness

History of Present Illness

  • HR 60’s, limp, acrocyanotic, with no response

  • Thermoregulation, Suctioning, Tactile stimulation

  • HR 50’s, some flexion, acrocyanotic, (+) grimace

  • Thermoregulation, Suctioning, Tactile stimulation, PPV

  • HR 100’s,some flexion, acrocyanotic, (+) grunting

  • Thermoregulation, Given blow by O2, Stimulation

  • HR 130’s, active, acrocyanotic, (+) crying,RR 50-60

  • Weaned off from O2

  • (+) Grunting, (+) retractions

  • Placed on O2 support via 10 lpm

  • NICU 3


Maternal obstetrical history

Maternal Obstetrical History

  • OB Index: G2P2 (2002)

  • Previous Pregnancy:

    Date: 2007

    Sex: Male

    BW: 2.7 kg

    Place: Perpetual Help Hospital

    Delivery Type: 1o Low-segment C.S.

    AOG: Full Term

    Complications: CephalopelvicDisroportion


Antenatal history

Antenatal History

  • LMP: September 04, 2008

  • Prenatal Checkups: 2 at PGH

  • Medications Taken: None

  • Illnesses/Infection: None

  • Alcohol/Tobacco Use: None


Labor

Labor

  • Onset of Uterine Activity: Spontaneous

  • Intensity of Contractions: Moderate

  • Membrane Status: Intact

  • Analgesia: None


Delivery

Delivery

  • Mode: Abdominal

  • Amniotic Fluid: Slightly Meconium Stained

  • Analgesia: Subarachnoid Block


Immediate neonatal period

Immediate Neonatal Period

  • APGAR Score: 5, 9

  • Resuscitation:

  • Supplementary O2 10 LPM via hood

  • Positive Pressure-Ventilation


Family history

Family History

  • (-) Hypertension

  • (-) Diabetes Mellitus

  • (-) Bronchial Asthma

  • (-) Blood Dyscrasias


Physical examination

PHYSICAL EXAMINATION


Case discussion

  • GENERAL APPEARANCE:

    limp, in respiratory distress

  • VITAL SIGNS:

    T: 36.6oCHR: 130 bpm RR: 50 cpm

    Wt: 2600 gLt: 49 cmHC: 32.5 cm

    CC: 31 cmAC: 28 cm

  • SKIN:

    acrocyanotic, (-) lesions, (+) cracking, rare veins


Case discussion

  • HEAD:

    (-) molding, (-) cephalhematoma, both fontanels

    flat and soft, (-) overlapping sutures, BT: 8cm,

    BP: 9cm, SOB: 9cm, OF: 10.5cm, OM: 11.5cm

  • EYES:

    (-) discharges, anicteric sclerae, both pupils equally reactive to light

  • EARS:

    (-) low-set ears, formed, firm with instant recoil


Case discussion

  • NOSE:

    (+) alar flaring, both nostrils patent, (-) discharges

  • MOUTH:

    (-) circumoral cyanosis, (-) cleft lip, formed

    tongue, (-) cleft palate

  • CHEST/LUNGS:

    (-) barrel-shaped, (+) subcostal & intercostal

    retractions, raised areola with 3-4 mm bud,

    (+) grunting,(-) tachypnea


Case discussion

  • HEART:

    adynamic precordium, (-) thrills, normal rate, regular rhythm, (-) murmur

  • ABDOMEN:

    globular but not distended, nonpalpable liver

  • UMBILICUS:

    translucent, (-) meconium stained,

    2 arteries and 1 vein

  • BACK:

    lanugo with bald areas, (-) dimpling, straight spine


Differential diagnosis

DIFFERENTIAL DIAGNOSIS


Primary working impression

PRIMARY WORKING IMPRESSION


Case discussion

  • Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9

  • Meconium Aspiration Syndrome vs. Neonatal Pneumonia

  • R/O sepsis


Course in the ward

COURSE IN THE WARD


Catcher s area

Catcher’s Area

an extended-spectrum penicillin: improved activity against gram-negative organisms but can be destroyed by -lactamases

-lactamase inhibitor

has synergistic effect with penicillins

  • Born on May 7, 2009, 4:57 p.m.

  • Started on Piperacillin-Tazobactam (75mkd) 195 mg IV q12

  • Started on Amikacin (15mkd) 40 mg IV OD


Catcher s area1

Catcher’s Area

Why?

Why?

Why?

Why?

Why?

Why?

Why?

Why?

  • Diagnostics:

    > CBC with PC> Na, K, Cl, Ca,

    > Blood typing> CXR APL

    > ABG> Blood C/S

  • Venoclysis with D10W (80) @ 9cc/hr

  • NPO, Hgt q8

  • O2 support at 10 lpm/hood


Catcher s area2

Catcher’s Area

COMPLETE BLOOD COUNT


Catcher s area3

Catcher’s Area

ARTERIAL BLOOD GAS

COMBINED METABOLIC AND RESPIRATORY ACIDOSIS


Case discussion

NICU


3 rd hour of life

3rd Hour of Life

S: (+) hypotension, (-) hypothermia, (-) dyspnea

O:pink all over, some flexion of extremities, weak cry

RR:24 HR:132 BP:30-40 T:36.6o O2:85-95%

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) grunting, clear breath sounds

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, fair pulses

A:Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia


3 rd hour of life1

3rd Hour of Life

P:

  • Given total of 50 cc PNSS IV bolus

  • Started on Dopamine @ 10mcg/kg/min to run for 1cc/hour (Dopamine 0.9cc + D5W 23.1cc)

  • UVC inserted


5 th hour of life

5th Hour of Life

S: (+) persistent desaturation, (-) tachycardia, (+) dyspnea

O:acrocyanotic, some flexion of extremities, weak cry

RR:72 HR:144 BP:40-50 T:36.7o O2:80%

(+) alar flaring, (-) circumoral cyanosis

equal chest expansion, (+) ICS retractions, (+) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, fair pulses

A:Full term, 37 weeks by PA, 2600 grams, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Sx vs. Neonatal Pneumonia


5 th hour of life1

5th Hour of Life

P:

  • Intubated with MV settings: FiO2100%, 18/3, RR 60 LT 0.4

  • D10W increased to run for 10 cc/hour


5 th hour of life2

5th Hour of Life

ARTERIAL BLOOD GAS

(post-intubation)

UNCOMPENSATED METABOLIC ACIDOSIS

(NaHCO3 5 meqs)


7 th hour of life

7thHour of Life

ARTERIAL BLOOD GAS

(post-NaHCO3)

COMPENSATED REPIRATORY ALKALOSIS


1 st day of life

1st Day of Life

S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever,

(+) BM x1, (+) UO x2, (-) jaundice

O:pink all over, good muscle tone, awake

RR:56 HR:128 T:36.7o O2:99%

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, strong pulses


1 st day of life1

1st Day of Life

CHEST X-RAY

CHEMICAL PENUMONITIS


1 st day of life2

1st Day of Life

BLOOD CHEMISTRY

HYPOCALCEMIA


1 st day of life3

1st Day of Life

ARTERIAL BLOOD GAS

COMPENSATED RESPIRATORY ALKALOSIS


1 st day of life4

1st Day of Life

Why?

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

P:

  • IVF shifted to D10IMB Ca 300 @ 10cc/hr

  • Decreased RR to 50 then by 2 every 2 hrs until 30

  • Decreased FiO2 by 5 every 2 hours until 60%


2 nd day of life

2nd Day of Life

S: (-) desaturation, (-) tachycardia, (-) dyspnea, (-) fever,

(+) BM x2, (+) UO x3, (-) jaundice

O:pink all over, good muscle tone, asleep

RR:44 HR:136 T:37.2o O2:99%

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, strong pulses


2 nd day of life1

2nd Day of Life

ARTERIAL BLOOD GAS

NORMAL ARTERIAL BLOOG GAS (????)


2 nd day of life2

2nd Day of Life

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, APGAR Score 5,9; Meconium Aspiration Syndrome vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis

P:

  • Once FiO2 60%, may start feeding with 5cc EBM every 3 hours per with strict aspiration precaution


2 nd day of life3

2nd Day of Life

P:

  • 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 every 2 hours until 21%

  • Wean RR by 2 every 2 hours until 10

  • Extract ABGs at RR=10


3 rd day of life a m

3rd Day of Life, A.M.

S: (-) tachycardia, (-) dyspnea, (-) fever, (-) jaundice

O:pink all over, good muscle tone, asleep

RR:44 HR:136 T:37.2o O2:99%

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, strong pulses

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis


3 rd day of life a m1

3rd Day of Life, A.M.

ARTERIAL BLOOD GAS

(post-extubation)

??????????????


3 rd day of life a m2

3rdDay of Life, A.M.

P:

  • Extubated

  • Placed on O2 hood FiO2 30%

  • Revised inotropes: Dopamine 0.5cc + D5W 23.5 cc to run at 1cc/hour, then consume, then discontinue

  • Racemic epinephrine nebulizationstarted, to continue 2 more doses 15 minutes apart


3 rd day of life p m

3rd Day of Life, P.M.

S: (-) fever, (+) jaundice, (+) coffe-ground material/ogt

O:pink all over, good muscle tone, asleep

RR:48 HR:152 T:36.7o

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

distended, soft, (-) masses

good capillary refill, strong pulses

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; PPHN precaution; r/o Sepsis


3 rd day of life p m1

3rdDay of Life, P.M.

P:

  • For TB DB IB

  • For CPT with proper shields

  • Dopamine discontinued

  • NCPAP 30% PEEP 5

  • ABGs

  • Feeding decreased to 30cc


4 th day of life

4th Day of Life

S: (-) dyspnea, (-) fever, (+) jaundice, (+) vomiting

O:pink all over, good muscle tone, asleep

RR:44 HR:148 T:37.0o

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, strong pulses

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; Hyperbilirubinemia no set-up


4 th day of life1

4th Day of Life

TOTAL, DIRECT, INDIRECT BIL.

NORMAL


4 th day of life2

4th Day of Life

Why?

Why?

P:

  • Maintained on phototherapy

  • NPO

  • Wean FiO2 by 5 q2 until 21%

  • Started on Famotidine 1mg IV q12

  • Given Vit. K 2mg slow IV push

  • ABGs ordered at 25% PEEP 5


5 th day of life

5th Day of Life

S: (-) dyspnea, (-) fever, (+) jaundice, (+) vomiting

O:pink all over, good muscle tone, asleep

RR:47 HR:152 T:36.8o

(-) alar flaring, (-) circumoral cyanosis

equal chest expansion, (-) ICS retractions, (-) grunting

adynamic precordium, (-) tachycardia, (-) murmur

globular, soft, (-) masses

good capillary refill, strong pulses

A:Full Term, 37 weeks by PA, 2600 g, AGA, Cephalic presentation, Delivered by repeat LSCS, AS 5,9; MAS vs. Neonatal Pneumonia; Hyperbilirubinemia no set-up


4 th day of life3

4th Day of Life

ARTERIAL BLOOD GAS

??????????????


4 th day of life4

4th Day of Life

CHEST X-RAY

ATELECTASIS, RIGHT UPPER LOBE

ATELECTASIS/CONSOLIDATION, MEDIAL SEGMENT OF RLL


5 th day of life1

5th Day of Life

Why?

Why?

P:

  • For repeat CBC with PC, blood CS, eletrolytes

  • To start Ceftazidime (50mkd) 130mg IV q12h

  • IVF revised to: D10IMB Ca 400 @ 13cc/hr

  • Please put patient on right side up


6 th day of life

6th Day of Life

COMPLETE BLOOD COUNT


6 th day of life1

6th Day of Life

BLOOD CHEMISTRY


6 th day of life2

6th Day of Life

TOTAL, DIRECT, INDIRECT BIL.


Meconium aspiration syndrome

MECONIUM ASPIRATION SYNDROME


Introduction

Introduction

  • Meconium-stained amniotic fluid may be aspirated during labor and delivery, causing neonatal respiratory distress.

  • Because meconium is rarely found in the amniotic fluid prior to 34 weeks' gestation, meconium aspiration chiefly affects infants at term and postterm.


Introduction1

Introduction

3 major constituents of meconium:

Intestinal secretions

Mucosal cells

Solid elements of swallowed amniotic fluid are the 3 major solid constituents of meconium.

Water - major liquid constituent, (85-95%)


Etiology

Etiology

  • Placental insufficiency

  • Maternal hypertension

  • Preeclampsia

  • Oligohydramnios

  • Maternal drug abuse

    (tobacco, cocaine)


Etiology1

Etiology

  • Maternal infection/chorioamnionitis

  • Inadequate removal of meconium from the airway prior to the first breath

  • Use of positive pressure ventilation (PPV) prior to clearing the airway of meconium


Pathophysiology

Pathophysiology

Fetal hypoxic stress

(head or cord compression)

Vagal stimulation

Mature gastrointestinal tract

Peristalsis

Rectal sphincter relaxation

Meconium passage


Pathophysiology1

Pathophysiology

Meconium + amniotic fluid

1. perinatal bacterial infection

2. erythematoxicum

3. stained amniotic fluid aspiration


Pathophysiology2

Pathophysiology

Aspiration induces hypoxia via 3 major pulmonary effects: 

1. airway obstruction

2. surfactant dysfunction

3. chemical pneumonitis


Pathophysiology3

Pathophysiology

1. Airway obstruction

  • Complete obstruction - atelectasis

  • Partial obstruction - ball-valve effect


Pathophysiology4

Pathophysiology

2. Surfactant dysfunction

  • free fatty acids of the meconium (eg, palmitic, stearic, oleic), have a higher minimal surface tension than surfactant

  • Meconium strip it from the alveolar surface, resulting in diffuse atelectasis


Pathophysiology5

Pathophysiology

3. Chemical pneumonitis

  • Enzymes, bile salts, and fats in meconium irritate the airways and parenchyma, causing a release of cytokines

  • results in a diffuse pneumonia that may begin within a few hours of aspiration


History1

History

Meconium in amniotic fluid

- required to cause meconium aspiration syndrome (MAS)

Green urine

- less than 24 hours after birth

- meconium pigments absorbed by lungs, excreted in urine


Clinical manifestations

Clinical Manifestations

Cyanosis

  • End-expiratory grunting

  • Alar flaring

  • Intercostal retractions

  • Tachypnea

  • Barrel chest in the presence of air trapping

  • Auscultatedrales and rhonchi (in some cases)


Clinical manifestations1

Clinical Manifestations

Yellow-green staining

  • Fingernails

  • Umbilical cord

  • Skin


Laboratory studies

Laboratory Studies

Acid-base status

  • Metabolic acidosis from perinatal stress

  • Respiratory acidosis from parenchymal disease and persistent pulmonary hypertension of the newborn (PPHN).


Laboratory studies1

Laboratory Studies

Serum electrolytes

  • sodium, potassium, and calcium

  • common perinatal stress complications:

    1. syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

    2. acute renal failure are frequent of


Laboratory studies2

Laboratory Studies

CBC Count

  • In utero or perinatalblood loss, as well as infection, contributes to postnatal stress

  • Hemoglobin andhematocrit

    - ensure adequate oxygen-carrying capacity

  • Neutropeniaorneutrophilia

    - may indicate perinatal bacterial infection


Chest findings

Chest Findings

Air trapping and hyperexpansion from airway obstruction.


Chest findings1

Chest Findings

Acute atelectasis


Chest findings2

Chest Findings

Pneumomedia-stinum from gas trapping and air leak


Chest findings3

Chest Findings

Left pneumothorax with depressed diaphragm and minimal mediastinal shift because of noncompliant lungs


Chest findings4

Chest Findings

Diffuse chemical pneumonitis from constituents of meconium


Chest findings5

Chest Findings

  • Gross overaeration of the lungs and bilateral nodular infiltrates

  • The nodular infiltrates represent areas of patchy or focal alveolar atelectasis and the overaerated spaces in between, compensatroy, focal alveolar overdistension


Management

Management

Meconium Aspiration

Intubation

Suctioning

(Tracheal suctioning)


Management1

Management

No clinical trials justify suctioning based on the consistency of meconium.

Avoid:

  • Squeezing the chest of the baby

  • Inserting a finger into the mouth of the baby


Guidelines for management of a baby exposed to meconium by aapnrp

Guidelines for Management of a Baby Exposed to Meconium by AAPNRP

NOT VIGOROUS

(minimal or absent respiratory effort,

poor muscle tone, or HR <100 beats/min)

Directlaryngoscopy intubation

and tracheal suctioning

(Suction for no longer than 5 seconds)


Guidelines for management of a baby exposed to meconium by aapnrp1

Guidelines for Management of a Baby Exposed to Meconium by AAPNRP

VIGOROUS

(good respiratory effort, crying, good muscle tone,

and HR >100 beats/min)

DO NOT electively intubate.

Clear secretions and meconium

from the mouth and nose

with a bulb syringe or a

large-boresuction catheter


Guidelines for management of a baby exposed to meconium by aapnrp2

Guidelines for Management of a Baby Exposed to Meconium by AAPNRP

In either case,

The remainder of the initial resuscitation steps should ensue and include:

drying,

stimulating,

repositioning, and

oxygen administration as necessary


Continued care in the nicu

Continued care in the NICU

  • Maintain an OPTIMAL THERMAL ENVIRONMENT

  • Minimal handling

  • SEDATION - to decrease agitation


Continued care in the nicu1

Continued care in the NICU

  • Continue RESPIRATORY CARE

    • Oxygen therapy

      - hood or positive pressure

      for adequate arterial oxygenation

    • Mechanical ventilation

      - minimize the mean airway pressure

      - short inspiratory time

      - oxygen saturations 90-95%


Continued care in the nicu2

Continued care in the NICU

  • SURFACTANT THERAPY

  • Nitric Oxide - pulmonary vasodilator of choice in PPHN

  • SYSTEMIC BLOOD VOLUME

  • BLOOD PRESSURE

    (Volume expansion, transfusion therapy, and systemic vasopressors)

    decrease: right-to-left shunt via PDA


Complications

Complications

Chronic lung disease

Infections


Prognosis

Prognosis

  • Most with complete recovery of pulmonary function

  • Intrapartum events initiating meconium passage may cause long-term neurologic deficits:

  • CNS damage

  • seizures

  • mental retardation

  • cerebral palsy


Hyperbilirubinemia

HYPERBILIRUBINEMIA


Pathophysiology6

Pathophysiology

  • Yellow color usually results from accumulation of unconjugated, nonpolar, lipid-soluble bilirubin pigment in the skin

  • May be due in part to deposition of pigment from conjugated bilirubin

  • Elevated levels of indirect, unconjugatedbilirubin potentially neurotoxic


Etiology2

Etiology

  • Increase load of bilirubin to the liver

    • Hemolytic anemia, polycythemia, shortened red cell life, increased enterohepatic circulation, infection

  • Damaged or reduced activity of the transferase enzyme or other related enzymes

    • Genetic deficiency, hypoxia, infection, thyroid deficiency


Etiology3

Etiology

  • Blocked transferase enzyme

  • Absence or decreased amounts of enzyme or reduced bilirubin uptake by liver cells

    • Genetic defect, prematurity


Differential diagnosis1

Differential Diagnosis

  • Jaundice appearing after the 3rd day and within the 1st week suggests bacterial sepsis or urinary tract infection

  • Other causes: syphilis, toxoplasmosis, CMV, enterovirus


Management2

Management

  • Regardless of the cause, goal of therapy is to prevent indirect-reacting bilirubin related neurotoxicity

  • Tx: phototherapy and exchange therapy


Case discussion

End...

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