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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 • • • • • • • 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: • • • • 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