Port-Foad NICU

Dr El Sayed Khalaf

MD Pediatric

Consultant Pediatric and Neonatology

CASE STUDY

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%

• 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.

• 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.

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.

• 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.

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%

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.

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.

• 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.

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%

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

• 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.

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.

• 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

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.

• 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.

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.

• 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.

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.

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.

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.

Growth Curves for Prematures

MRI after 1 M of discharge

Thank You