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NICU AUDIT
February 2014
JPB
• Born on February 14,
2014
• Live preterm baby girl
• Delivered via Scheduled
Primary Cesarean Section
for Maternal Condition
(Breast Cancer)
• 41 y/o
• G2P2 (1102)
• 28 5/7 weeks AOG
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BW 1250 g
BL 38 cm
HC 26 cm
CC 23 cm
AC 21 cm
MT 30, AGA
AS 9,9
Delivery
• Apgar 1 min: HR >120’s, acrocyanotic, good
cry and activity, spontaneous breathing
• Apgar 5 min: HR >120’s, acrocyanotic, good
cry and activity, spontaneous breathing
• Immediately placed in a food grade plastic bag
• O2 saturation: >85%
• Newborn care was rendered
Problem List:
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Respiratory Distress Syndrome
Infection
Apnea of Prematurity
Hyperbilirubinemia of Prematurity
Prob 1: Respiratory Distress Syndrome
2nd Hour of life
Subjective
•Grunting
•Spontaneous
breathing
•No cyanosis
20 minutes after
•No improvement
of the grunting
Objective
•RR 60
•Fair air entry
•Subcostal,
intercostal and
suprasternal
retraction
Assessment
T/C Respiratory
Distress
Syndrome,
Prematurity
Plan
•Hook to nasal
CPAP
•Oxacillin,
Cefotaxime,
Amikacin
•Intubation done
•Surfactant
therapy (4ml)
given
•Umbilical
catheterization
VBG
pH
pCO2
PO2
HCO3
O2
BE
7.328
61.7
45.1
32.3
76.3
5.3
Compensated Respiratory
Acidosis
Chest Xray
Consider Hyaline Membrane Disease, cannot
totally rule out Neonatal Pnemonia
Blood
Culture
No Growth (7 days)
CBC
Hgb
Hct
WBC
Band
Neu
Lymp
Mon
Eos
Plt
151
45
7.9
4
48
42
5
1
239
HGT
82
4nRBC
/100
WBC
Problem 2: Hyperbilirubinemia
1st day of life
Subjective
•Intubated
•FiO2 40%
•RR 35
•PIP 14
•PEEP 3.8
•s/p surfactant
therapy
•Mother had a
would culture:
Heavy growth of
S. aureus:
sensitive to all
except Penicillin
Objective
Assessment
Plan
•VS: HR 144, RR
65, T 36.9 O2 sat
98%
•Jaundice to
upper chest
•Good air entry,
subcostal,
intercostal,
suprasternal
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Respiratory
Distress
Syndrome vs
Neonatal
Pneumonia,
Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified
•Labs: Bilirubin
Levels, CRP, Chest
Xray, Hgt
•Single Overhead
Phototherapy
•Oxacillin,
Cefotaxime,
Amikacin
Bilirubin Levels
Total
Direct
Indirect
5.21
0.38
4.92
Chest Xray
Consider Hyaline Membrane Disease, with
interval improvement in the Lung Status
CRP
0.21 mg/dl
HGT
152
VBG
pH
pCO2
PO2
HCO3
O2
BE
7.354
59.8
28.4
33.2
50.3
6.6
Compensated Respiratory
Acidosis
4th day of life
Subjective
•Extubated
•Shifted to nasal
IPPV
FiO2 30%
PIP 12/4
RR 15
iT 0.4
FR 8
Objective
•VS: HR 178, RR
68, T 36.8 O2 sat
100%
•Jaundice to face
•Good air entry,
subcostal,
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Assessment
Plan
Mild Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified
•Labs: Hgt (119)
•Single Overhead
Phototherapy
•Epinephrine 0.1
ml + 1.5 ml NSS
every 30 mins
for 2 doses
•Aminophylline 6
mg loading dose
(4.8mg/kg), 1 mg
every 12 hrs (0.8
mg/kg)
•Oxacillin,Cefota
xime, Amikacin
5th day of life
Subjective
•No desaturations
•No cyanosis
Objective
•VS: HR 177, RR
50, T 36.8 O2 sat
100%
•Jaundice to
abdomen
•Good air entry,
subcostal,
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Assessment
Mild Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified
Plan
•Labs: Hgt,
Bilirubin level,
Na, K
•Single Overhead
Phototherapy
•Shifted to nasal
cannula at 0.5
lpm, then
discontinued
•Oxacillin,
Cefotaxime,
Amikacin
Bilirubin Levels
Total
Direct
Indirect
8.06
0.45
7.75
Na
K
132
6.3
HGT
87
LRZ
Prob 3: Infection and Apnea
7th day of life
Subjective
•No desaturations
•No cyanosis
•apnea 5-10
seconds, HR 90’s,
O2 sats 64-69%
Objective
•VS: HR 152, RR
67, T 36.6 O2 sat
98%
•Jaundice to
abdomen
•Good air entry,
no retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Assessment
Apnea, Mild
Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified
Plan
•Labs: CBC, hgt,
Chest Xray
•Single Overhead
Phototherapy
(intermittent)
•O2 support
discontined
•Aminophylline
increased to 2
mg IV (1.6
mg/kg)
•Antibiotics
shifted to
Piperacillin-
CBC
Hgb
Hct
WBC
Band
Neu
45 hgt,
22 chest
9 xray
61
• CBC,
150
Chest Xray
HGT
Lymp
Mon
Eos
Plt
22
7
1
370
Hyaline Membrane Disease with further
improvement in lung status
68
Slight
toxic
granules
14th day of life
Subjective
Objective
Assessment
•Episodes of
desaturations
•Episodes of
apnea (5-10
seconds, HR 80’s90’s, O2
saturation 70%)
w/c responds to
tactile stimulation
•VS: HR 150, RR
49, T 36.6 O2 sat
95%
•pink
•Good air entry,
shallow subcostal
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Apnea, Mild
Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified,
resolved
Plan
•Labs: CBC, hgt
•O2 support
•Aminophylline
resumed
•PiperacillinTazobactam
increased to 120
mg (100
mg/kg/dose)
CBC
Hgb
Hct
WBC
Band
Neu
43 hgt,
14.4chest
20 xray
47
• CBC,
143
HGT
92
Lymp
Mon
Eos
Plt
16
10
7
522
Slight
toxic
granules
15th day of life
Subjective
Objective
Assessment
Plan
•Episodes of
desaturations
•Episodes of
apnea (10-20
seconds, HR 60’s70’s, O2
saturation 70%)
w/c responds to
tactile stimulation
•VS: HR 150, RR
49, T 36.6 O2 sat
95%
•Pink, mottled
skin
•Good air entry,
shallow subcostal
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Apnea, Mild
Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified,
resolved
•Labs: blood
culture,
urinalysis, Chest
xray, Na, K,
Bilirubin levels,
Hgt, blood gas
•Nasal CPAP
intubation
•Aminophylline
increased to
every 8 hours
•Pip-Taz
discontinued
shifted to
Meropenem 24
mg IV every 12
VBG
pH
pCO2
PO2
HCO3
O2
BE
7.24
55.7
33
24
26
-3.0
Respiratory Acidosis
Chest Xray
unchanged bilateral lung opacities consistent
with resolving hyaline membrane disease
Blood
Culture
No growth for 24 hrs
Urinalysis
RBC
WBC
Epithelial
Cast
Bacteria
2
5
61
0
14
Hgb
Hct
126
37
HGT
Na
K
iCal
139
4.9
139
92
Bilirubin Levels
Total
Direct
Indirect
4.54
0.38
4.22
LRZ
16th day of life
Subjective
Objective
Assessment
Plan
•Intubated
•FR 8
•FiO2 20
•RR 20
•PIP 10
•PEEP 4
• iT 0.5
•No desaturations
•VS: HR 141, RR
52, T 37 O2 sat
100%
•Pink
•Good air entry,
shallow subcostal
retractions
•Good cardiac
tone
•Soft abdomen
•Full pulses
Apnea, Mild
Respiratory
Distress
Syndrome, Sepsis,
unspecified,
Hyperbilirubinemi
a, unspecified,
resolved
•Labs: Blood gas
•Nasal CPAP
intubation
•Aminophylline
decreased to
every 12 hours
•Meropenem 24
mg IV every 12
hrs (20
mg/kg/dose)
VBG
pH
pCO2
PO2
HCO3
O2
BE
7.261
63.4
35.7
28.4
57.9
-0.2
Respiratory Acidosis
Current Diagnosis
Prematurity, Very Low Birth Weight,
Apnea of Prematurity, Sepsis, Mild
Respiratory Distress Syndrome,
Hyperbilirubinemia, unspecified,
Resolved