Baby Girl Barcelon

DATE OF BIRTH: 06/15/2013 TIME OF BIRTH: 07:15 AM

Maternal History
Born to a 25-year-old G1P0 analyst, single with a

25-year-old partner, businessman Non-smoker, non-alcoholic beverage drinker, denies use of ilicit drugs Denies exposure to viral exanthema, radiation, teratogens/ abortifacients

Maternal History
Prenatal check-up started at 6wks AOG with a

private OB (total 8 visits) Normal CBC and UA UTZ done 3x, unremarkable HbsAg nonreactive OGCT normal

Maternal History
8 weeks AOG Bacterial vaginosis Unrecalled suppository x 7days Resolution of foul smelling discharge 25-26 weeks AOG Bacterial vaginosis Clotrimazole suppository x 3 days Resolution of vaginal discharge (?)

Maternal History
Not a known hypertensive (-) DM (-) thyroid disorder

(-) known allergies

Labor History
2 days prior to delivery

(+) vaginal spotting and hypogastric pain

1 day prior to delivery

(+) persistence of vaginal spotting and hypogastric pain Admitted: started on nifedipine 10mg q6, given betamethasone 12mg x 2 doses, progesterone 200mg/tab 1 tab q6
CBC Hgb 118 WBC 15.7 Neut 0.92 Eos 0 Hct 0.35 Plt 266 Lympho 0.07 Mono 0.01 Urinalysis Yellow Sugar ++ RBC 1-2 Sl. Turbid Pus 1-3 Bact ++ Sp Gr 1.02 Alb +

Labor History
Hours prior to delivery (+) irregular uterine contractions Three hours prior to delivery (4:00am) (+) increasing frequency of uterine contractions (+) worsening hypogastric pain Two hours prior to delivery (5:00am) IE: 7cm dilated

Outcome
Live, preterm, singleton female delivered via NSD,

BW 900g, BL 35cm, HC 20cm, AS 8,9, MT 2829wks, AGA

Course in the Wards

Hx/PE
At birth HR 160s RR 50s Acrocyanotic Thermoregulated (+) retractions

LABORATORY
ABG pH 7.36 pO2 98 HCO3 18.2 CBC Hgb 113 WBC 10.6 Neut 0.51 Mono 0.01 Babygram Hazy infiltrates on both lung fields Hct 0.33 Plt 247 Lympho 0.48 pCO2 32

MANAGEMENT
NPO. IVF started
NCPAP FiO2 25% O2FR 6 CA 5.7

O2 sat 97% PEEP 5 BE -5.7

Started ampicillin and gentamicin

9th hour of life

HR 150s O2 sat 75% (-) respiratory effort HR 120s O2 sat 69% (-) respiratory effort

Aminophylline (LD 8mkdose MD 2.2mkdose

16th hour of life

Nasal SIMV FiO2 25% P/P 12/4

VR 20
IT 0.5

PSV 2(6)

Hx/PE
24th hour of life HR 110 Jaundiced to chest O2 sat 58% (-) respiratory effort (+) jaundiced to chest

LABORATORY
CBC Hgb 115 WBC 7.3 Neut 0.53 Eos 0.04 Hct 0.33 Plt 229 Lympho 0.43 nRBC 6

MANAGEMENT
Transfuse PRBC 10ml/kg Phenobarbital (LD 20mkdose MD 3mkd) Aminophylline increased to 2.2mkdose q8
Nasal SIMV
FiO2 25% P/P 10/3 PSV 2(5)

Peripheral smear No abnormal WBC, RBC anisocytosis, poikilocytosis, platelet adequate

VR 20 IT 0.5

Retic ct 26 Hgt 195 CRP 1.91

PE 5-7, EL 12-15 TB 6.10 DB 0.30 IB 5.80

IVF: D10 D5 D4
Na 137 K 3.53 TCa 8.02

Single bluelight phototherapy started

48th hour of life

HR 120s O2 sat 70% (-) respiratory effort

Ampicillin and gentamicin shifted to meropenem and amikacin Reload phenobarbital (5mkdose)

Hx/PE
57th hour of life HR 190s RR 50 O2 sat 97-98% Thermoregulated Fair pulses CRT 3 secs

LABORATORY
ABG pH 7.198 pO2 119.2 HCO3 17.9 pCO2 46.2 O2 sat 97.1% BE -10.2

MANAGEMENT
PNSS 9ml (10ml/kg) bolus Dopamine (5mcg/kg/min) started
MV Settings
FiO2 30% P/P 12/4 PSV 2(6) VR 20 IT 0.5

58th hour of life

HR 170-180 Poor pulses CRT 2-3 secs Firm fontanelles

CBC Hgb 115 WBC 7.3 Neut 0.53 Eos 0.04 Hct 0.33 Plt 229 Lympho 0.43

PNSS 9ml (10ml/kg) bolus Dobutamine (10g/kg/min) started Increased dopamine (10g/kg/min) FFP (10ml/kg) transfusion PRBC (10ml/kg) transfusion
MV Settings

64th hour of life

ABG pH 7.198 pO2 119.2 HCO3 17.9 pCO2 46.2 O2 sat 97.1% BE -10.2

FiO2 30% P/P 10/5 PSV 2(7)

VR 40 IT 0.5

Hx/PE
68th hour of life HR 203 RR 50s O2 sat 100% Fair pulses CRT 2 secs HR 190 RR 50s O2 sat 99% Fair pulses CRT 2 secs

LABORATORY

MANAGEMENT
PNSS 9ml (10ml/kg) bolus

PNSS 9ml (10ml/kg) bolus Increased dopamine (12g/kg/hr 15g/kg/hr)

HR 210 RR50s O2 sat 100% Fair pulses CRT 2 secs

ABG

PNSS 9ml (10ml/kg) bolus Epinephrine drip (0.1g/kg/min) started Intubated (ET sz 2.5, Level 6)
MV Settings

pH 7.193
pO2 76.0 HCO3 17.0

pCO2 44.3
O2 sat 91.1% BE -11.1

FiO2 50%
P/P 10/4 PSV 0(4)

VR 40
IT 0.5

HR 180s RR 50s Good pulses CRT< 2 secs

FFP (10ml/kg) transfusion

Hx/PE
Day 4 of life HR 180s RR 50s-60s O2 sat 98% Thermoregulated Good pulses CRT <2secs

LABORATORY
ABG pH 7.4 pO2 146.5 HCO3 12.2 pCO2 19.6 O2 sat 98.8% BE -9.2

MANAGEMENT
MV Settings FiO2 40% P/P 10/3 PSV 0 VR 30 IT 0.5

Decrease epinephrine drip (0.5g/kg/min) d/c IVIG infusion (750mg/kg/dose) FFP (10ml/kg) transfusion Seen by Pedia Neuro A> Neonatal seizures t/c Intracranial hemorrhage For cranial ultrasound Seen by Pedia Hematology A> Anemia prob sec to infection
MV Settings FiO2 30% VR 20

P/P 8/3
PSV 0

IT 0.5

Hx/PE
Day 5 of life HR 160s-170s RR 50s O2 sat 100% (+) recurrent hypothermia (-) retractions Clear, equal breath sounds Good pulses CRT <2secs

LABORATORY

MANAGEMENT
MV Settings FiO2 25% P/P 8/3 PSV 0(3) VR 10 IT 0.5 I;E 1:11

Dobutamine 5mcg/kg/min IVIG #2 infusion (750mg/kg/dose) Extubated

NCPAP
FiO2 30% PEEP 5 O2 0.3 O2FR 6 CA 5.7

FFP transfusion 10ml/kg

(+) 2 episodes of apnea (HR 50s, O2 sat 80s, irregular respirations) Improved after PPV Pulses full, CRT <2secs

Shifted to nasal SIMV

MV Settings FiO2 30% P/P 10/3 PSV 2(5) VR 20 IT 0.5

Hx/PE
Day 5 of life (+) recurrent apnea (HR 80s O2 sat 80s, irregular respirations) Fontanelles soft

LABORATORY
ABG pH 7.273 pCO2 42.3

MANAGEMENT
Intubated ET sz 2.5 Level 6
MV Settings FiO2 25% VR 20 IT 0.5

pO2 75.8
HCO3 19.5 CBC Hgb 112 WBC 6.4 Neut 0.59 Eos 0.04

O2 sat 93%
P/P 10/3 BE -7 PSV 0

Hct 0.33 Plt 238 Lympho 0.36 Mono 0.01

Aminophylline increased (2.8mkdose q8) Transfuse PRBC 10ml/kg

Bands 0.01

Phototherapy discontinued
Na 140 K 4.38 Tca 9.48 BUN 27.75 Crea 0.91 ECC 12.7 TB 3.10 DB 0.6 IB 2.5

CHEST XRAY Mild regression of previously noted infiltrates

Hx/PE
Day 6 of life (-) recurrence of apnea HR 160s-170s RR 40s Full pulses CRT <2secs Fontanelles soft HR 140s-170s RR 30s-50s O2 sat 94-100% (+) jaundiced to chest Clear breath sounds Soft abdomen Full pulses CRT< 2secs

LABORATORY

MANAGEMENT
Dopamine 5mcg/kg/min Dobutamine discontinued
MV Settings

FiO2 25%
P/P 8/3 PSV 0

VR 20
IT 0.5

Day7 of life

TB 10.70
DB 0.30 IB 10.40

PE 5-7
EL 12-15

Dopamine discontinued Trophic feeding (1ml q4) Fluconazole prophylaxis Double phototherapy
MV Settings FiO2 25% P/P 8/3 VR 8 IT 0.5

Cranial UTZ Smooth sulci (-) hemorrhage

PSV 0

Extubation done NIMV

MV Settings FiO2 30% P/P 10/4 PSV 2(6) VR 10 IT 0.5

Hx/PE
Day 7 of life (+) recurrent apnea HR 69 O2 sat 69% (+) shallow respirations Good pulses, CRT<2 secs, soft fontanelles

LABORATORY
CBC Hgb 142 WBC 15.4 Neut 0.52 Eos 0.02 ABG pH 7.232 pO2 55.5 HCO3 16.4 pCO2 39 O2sat 81.52 BE -10.5 Hct 0.42 Plt 287 Lympho 0.43 Mono 0.03

MANAGEMENT
Hold feeding
MV Settings FiO2 30% P/P 16/5 PSV 2(7) VR 20 IT 0.5

Na 136 K 4.45 TCa 9.76

Hx/PE
Day 8 of life (+) recurrent apnea HR 70s O2 sat 59% (-) respiratory effort (+) cyanosis (+) gr 3/6 holosystolic murmur @ left parasternal border Pulses full and equal

LABORATORY
15L ECG w/ rhythm strip Sinus tachycardia, R axis, RVH normal for age ABG pH 7.135 pO2 58.8 HCO3 18.6 pCO2 55.3 O2sat 79% BE -11.4

MANAGEMENT
Decrease IVF (130ml/kg) Referred to Pedia Cardio A> PDA
MV Settings FiO2 30% P/P 16/5 PSV 2(7) VR 20 IT 0.5

ABG pH 7.185 pO2 84.3 HCO3 15.5 pCO2 41.1 O2sat 93% BE -12.5

Intubated (ET sz 2.5 Level 6)

MV Settings (PCV mode) FiO2 60% P/P 12/4 VR 30 IT 0.5

HCO3 correction Phenobarbital (LD 10mkdose, MD 3mkd)

6hrs post double photo TB 6.7 DB 0.1 IB 6.6

Double phototherapy single phototherapy

Hx/PE
Day 8 of life RR 40 (+) dusky (+) dec BS, R Good pulses CRT <2secs

LABORATORY
CXR (PA, lat) Large pneumothorax, R

MANAGEMENT
Needling done, R 4th ICS obtained 28ml air Referred to TCVS for CTT insertion
MV Settings (PCV mode) FiO2 55% P/P 10/3 VR 20 IT 0.5

CXR (PA, lat) Reexpansion of R lung (+) infiltrates at R lower lung field

MV Settings (SIMV)

FiO2 50%
ABG (post HCO3 correction) pH 7.231 pO2 129.6 HCO3 9.9 pCO2 23.6 O2sat 98% BE -15.7 P/P 8/3

VR 30
IT 0.5

MV Settings (SIMV) FiO2 40% P/P 8/3 VR 25 IT 0.5

Serum Cl Anion gap Serum ammonia Urine ketones

108.5 11.1-17.6 114.21 (-)

Referred to Genetics A> t/c Inborn error of metabolism P> For expanded NBS, urine organic acid analysis, urine metabolic panel Limit AA to 1g/kg/day

Hx/PE
Day 9 of life (+) O2 desaturation (80s) ~10-15mins (+) tongue thrusting (+) rhythmic movement of extremities (+) 2 more seizure episodes Day 10 of life (+) occasional bradypnea (RR 30s) Shallow to no respiratory effort O2 sat 89-91% 24hr seizure-free (+) recurrent seizure (O2 sat 79%, HR 160s, pallor, tongue thrusting)

LABORATORY

MANAGEMENT
Phenytoin (LD 19.5 mkdose, MD 5.9mkdose) For neonatal EEG

Midazolam drip started (0.1mg/kg/hr)

ABG MV Settings (PCV mode)

pH 7.311
pO2 59.5 HCO3 18.2

pCO2 36.1
O2 sat 87.8% BE -7

FiO2 40%
P/P 8/3 I:E 1:2

VR 50
IT 0.5

Decreased midazolam drip (0.04mg/kg/hr) Reload phenobarbital (10mkdose) Increase midazolam drip (0.1mg/kg/hr 0.2mg/kg/hr)

Hx/PE
Day 11 of life (+) recurrence of seizure (O2 desat 78%, tongue thrusting, pallor, HR 160s)

LABORATORY

MANAGEMENT
Increased midazolam drip (0.4mg/kg/hr)

CBC

(+) recurrence of seizure (O2 desat 70s, no respiratory effort) ~20mins

Hgb 103 WBC 18.7 Neut 0.80 Mono 0.02

Hct 0.31 Plt 263 Lympho 0.18

Midazolam stat dose (0.15mg/kg/dose) Diazepam stat dose (0.33mg/kg/dose)

MV Settings (PCV mode) FiO2 40% VR 30 IT 0.5

Na 143 K 4.92 TCa 10.07 ABG pH 7.193 pO2 78 HCO3 23 pCO2 59.9 O2 sat 91.8 BE -6.3

P/P 10/3 I:E 1:1

Shift amikacin to vancomycin (15mkd) Fluconazole therapeutic dose Transfuse PRBC 10ml/kg

Bld CS#1 Roseomonas gilardii after 10days (S: Meropenem) Bld CS#3: (-) growth Urine CS: (-) growth Lumbar puncture: not done Phenobarbital level: 63.9

D/c phenobarbital and phenytoin Start levetiracetam (10mkd)

Hx/PE
Day 12 of life (+) 2 episodes of apnea Dusky Fair pulses HR 130s-150s (+) O2 desat 59% with no improvement on bagging Preductal 91% Postductal 59% O2 sat Preductal 90% Postductal 84%

LABORATORY
ABG pH 7.169 pO2 51.6 HCO3 23.3 pCO2 64.1 O2 sat 74% BE -6.8

MANAGEMENT
Dopamine started (10mcg/kg/min) MgSO4 (LD 200mg/kg, MD 30mg/kg/hr)
MV Settings (PCV mode) FiO2 100% P/P 12/4 I:E 1:3 VR 60 IT 0.5

Dobutamine (10mcg/kg/min)

Hx/PE
Day 14 of life O2 sat 97-100% (preductal and postductal) Good chest rise

LABORATORY
ABG pH 7.346 pO2 213.5 HCO3 16.9 pCO2 31.0 O2 sat 99.4% BE -7.2

MANAGEMENT
MV Settings (PCV mode) FiO2 100% P/P 10/3 I:E 1:3 VR 40 IT 0.5

Decrease MgSO4 (15mg/kg/hr) then to consume Day 15 of life EEG Start pyridoxine (LD 100mg MD 50mg) Decrease midazolam 0.1mg/kg/hr 0.05mg/kg/hr Midazolam stat dose 0.15mkdose x2 Diazepam stat dose 0.3mkdose x2 Loaded levetiracetam 10mkdose Increase midazolam drip 0.2mg/kg/hr

Day 16 of life

(+) recurrence of seizure ~1hr (O2 desat 72%, dusky, HR 160s, tongue thrusting, no respiratory effort)

Thank You.