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Mortality baby Isaac favour (3) psediatric residence doctors
- 1. SCBU outborn mortality By OnuzulikeJennifer 25/9/24
- 2. History • I.F. an11 days old male admitted into SCBU at 6 hours of life on 8/9/24 at 8:30am and died on 18/9/24 at 2:30pm after spending 10 days 6 hours on admission.
- 3. History He presented withcomplaints of • Prematurity at 33 weeks • No cry at birth • Fast breathing from birth
- 4. History • He wasdelivered at 33 weeks • He did not cry at birth and was resuscitated, said to have cried poorly after 2 mins of resuscitation. • Fast breathing was noticed subsequently. There was no bluish discolouration of lips and extremities. He was commenced on intranasal oxygen and brought to UPTH for expert care.
- 5. History • Pregnancy andbirth History: Pregnancy was supervised at gifted hands hospital Oyigbo from 2 months gestation. • Mother was seronegative to HIV, Hepatitis B and C and not reactive to VDRL. Blood group was O rhesus D positive. • She received 2 doses of intramuscular tetanus toxoid and 2 doses of Sulfadoxine-Pyrimethamine for malaria chemoprophylaxis.
- 6. History • There wasno history of fever or rash in first trimester. There was no history of intake of Tobacco, alcohol or herbal concotion. • Obstetric scan done at 2 months and 4 months were essentially normal. • Pregnancy was complicated by elevated blood pressure at 30weeks and proteinuria for which she was comenced on Tabs Aldomet and Nifedipine, with
- 7. History poor blood pressurecontrol, she was subsequently admitted and placed on bed rest. • Three weeks into admission, she had spontaneous preterm labour which lasted for about 10hours. Outcome was a live male baby who did not cry at birth, weighed 2.3kg. She had peripartum pyrexia and vaginal discharfge for which she received intravenous antibiotics. There was no history of prolonged rupture of membrane.
- 8. History • Had peripartumpyrexia and vaginal discharge for which she received oral medications.Birth weight was 2.3kg.
- 9. History Family and socialHistory: • He was the Second child of parents in a monogamous family setting. Sibling is a 3 year old female alive and well delivered at 34 weeks. Mother also had pre- eclampsia in that pregnancy. • She has had two still births at 33 and 34 weeks gestation respectively. • Mother is a 36 year old petty trader with secondary level of education.
- 10. History • Father isa 38 year old account personnel in a private firm. Family reside in a one bedroom apartment.
- 11. Examination • General examination:Very ill baby in severe respiratory distress, with intercostal and subcostal recessions, peripherally cyanosed, grunting, hypothermic (temperature< 350 c) anicteric, no peripheral edema. SP02 95% on intranasal oxygen via CPAP. RBG 5.6mmol/l. • Weight 2.2kg • Dubowitz corresponded to 33 weeks gestation.
- 12. Examination • Digestive Abdomen wasfull, moved with respiration Soft Liver tipped Spleen was not palpable Kidneys were not ballotable • Cardiovascular system HR:124b/min S1S2
- 13. Examination • Central nervoussystem Conscious AF flat and normotensive OFC 30cm Suck absent Grasp poor Normal tone in limbs Moro incomplete
- 14. Examination • Respiratory RR 84c/min Decreasedair entry • Genitourinary system: Immature male external genitalia Left undescended testes
- 15. Diagnosis • He wasadmitted as a case of preterm low birth weight (AGA) with respiratory distress syndrome • Presumed neonatal sepsis- Congenital Pneumonia in a child with severe perinatal asphyxia.
- 16. Investigations Hb 17g/dl Normal PCV52% Normal TWBC 13.0 x 109 /l Normal Neut 56% Normal Lymphocyte 35% Normal Platelet 198 x 109 /l Normal
- 17. Investigations Sodium 138mmol/l normalCalcium 1.3mmol/l Decreased Potassium 4.2mmo/l normal Magnesium 1.9mmol/l Normal Chloride Phosphate 1.8mmmol/l Normal Bicarbonate 24mmol/l normal Creatinine 30umol/l Normal Repeat sodium 136mmol 5/9/24 Normal Repeat Potassium 3.6mmol/l Normal
- 18. Investigations • Chest x-raywas requested but was not done because he was in severe respiratory distress and was CPAP dependent.
- 19. Treatment He was placedon NPO and received • Intranasal oxygen via improvised bubble CPAP • Intravenous Ceftazidine at 50mls/kg= 110mg 12 hourly • Intravenous Caffeine loading dose 20mg/kg= 44mg stat then 5mg/kg= 11mg daily • Intravenous 10% dextrose water at 70mls/kg/day= 60mls and changed to 10% dextrose water in 1/5th saline.
- 20. Treatment • Intravenous Genticinat 3mg/kg= 1.2mg 12hourly • He was nursed in an incubator • Phototherapy was commenced • RBG was being monitored and remained normal • Fluid Input and output monitoring was done. • Urine output ranged from 1.3mls/kg/hr to 1.5mls/kg/hr
- 21. Review • With retrievalof serum calcium result an additional diagnosis of Hypocalcaemia was made. • He received intravenous calcium gluconate bolus at 2mls/kg= 1.6mls • Maintenance dose of 4mls/kg= 8mls was continued.
- 22. Review • Four hoursinto admission, he had an apneic attack .Vital signs at this time were • Temperature 370 c, HR 30b/min RR 0c/min, SPO2 unrecordable, RBG 5.6mmoll/l • IPPV and cardiac massage were commenced, CPAP was discontinued and intranasal oxygen therapy commenced. IV Adrenaline 1ml 1:10,000 dilution was given.
- 23. Review • He regainedspontaneous respiration after 5minutes of active resuscitation but subsequently became unconscious BCS E0V1M0 1/5. • Third day into admission he regained consciousness however he was still critically ill. His vital signs were: Temp 360 c, RR 104c/min, HR 14ob/min, SPO2 44 in room air 97% on intranasal oxygen via CPAP.
- 24. Review • Trophic feedingwas commenced at 20mls/kg. He received 5mls 3 hourly via orogastric tube. • He was maintained on CPAP as he was not saturating well off oxygen.
- 25. Review • Six daysinto admission his condition continued to deteriorate. He was, noted to have bilateral pitting pedal edema up to the knee, he was pale and also icteric. • An additional diagnosis of ?Hypoproteinemia, severe anaemia and Neonatal jaundice were made. • Urgent serum total protein and albumin, PCV and SB were requested. • Total protein 40umol/l(decreased) • Albumin 2g/dl (decreased) • PCV done was 28%
- 26. Review SB results 14/9/246 days old 144umol/l 93 16/9/24 110umol/l 80 17/9/24 102 umol/l 65
- 27. Review • Phototherapy wascontinued • He had double volume exchange blood transfusion on account of severe anaemia with 357 mls of whole blood under intravenous ;lasix cover and was well tolerated. • 10 days into admission his condition deteriorated further, the pedal edema progressed to mid thigh. His urine output however was between 1.5-2mls/kg/hr. • He was commenced on intravenous lasix at 1mg/kg = 2mg 12 hourly
- 28. Review • Repeat totalprotein and albumin was requested • Urgent PCV was 45% • Intravenous antibiotics was changed to Meropenem at 40mg/kg/dose= 100mg 8 hourly • Intravenous fluid 10% dextrose water in 1/5th saline was reduced to half maintenance • He was on EBM 15mls 3 hourly
- 29. Terminally • Child wassuddenly noted to have become apneic . Vital signs at this time were Temp 360 c , HR 40b/min, SP02 was 27%, RBG 8.6mmol/l. • IPPV and cardiac massage was commenced. • 1ml of I in 10,000 dilution of Intravenous adrenaline was administered. • He had copious vomitting of altered blood by mouth and nose and was suctioned. Intravenous Vitamin K 5mg stat was given.
- 30. Terminally • He failedto respond to resuscitative measures and was certified clinically dead on 18/9/24 at 2:30pm after spending 11days 6 hours on admission. • Repeat total protein and albumin retrieved post mortem showed total protein of 36g/l( decreased) and albumin of 22g/l(decreased) • Blood culture showed heavy growth of Klebsiella specie sensitive to Meropenem.
- 31. Summary • I havepresented I.F. an 11 days old male admitted into SCBU at 6 hours of life on 8/9/24 at 8:30am and died on 18/9/24 at 2:30pm after spending 10days 6 hours on admission. • He presented with complaints of prematurity at 33 weeks, no cry at birth and fast breathing from birth.
- 32. Summary • Pregnancy wassupervised in a private hospital and was complicated by preeclampsia ta 30 weeks. At 33 weeks mother had spontaneous vertex delivery of a live male baby who did not cry at birth and was resuscitated.
- 33. Summary • On examination,he was a very ill baby in severe respiratory distress, with intercostal and subcostal recessions, peripherally cyanosed, grunting, hypothermic (temperature< 350 c) anicteric, no peripheral edema. SP02 95% on intranasal oxygen. RBG 5.6mmol/l. RR 84c/min HR 124b/min. • Weight 2.2kg • Dubowitz corresponded to 33 weeks gestation.
- 34. Summary • He wasmanaged as a case of preterm low birth weight (AGA) with respiratory distress syndrome • Presumed neonatal sepsis- Congenital Pneumonia, neonatal jandice, hypoproteinemia, hypocalacaemia in a child with severe perinatal asphyxia.
- 35. Summary • He receivedIntravenous Cefazidine which was changed to Meropenem, Intravenous dextrose water, Caffeine, Lasix, intranasal oxygen via improvised bubble CPAP. • He had DVEBT for severe anaemia of 28%.
- 36. Summary • His conditioncontinued to deterioriate. 10 days into admission, he suddenly became apneic. Active resuscitation was commeneced and he was certified clinically dead on 18/9/24 at 2:30pm after spending 11 days 6 hours on admission.