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 .

35 Plt 266 Lympho 0.7 Neut 0.07 Mono 0.01 Urinalysis Yellow Sugar ++ RBC 1-2 Sl.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 q6.02 Alb + . progesterone 200mg/tab 1 tab q6 CBC Hgb 118 WBC 15. given betamethasone 12mg x 2 doses. Turbid Pus 1-3 Bact ++ Sp Gr 1.92 Eos 0 Hct 0.

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 .

9. MT 2829wks. AGA . BL 35cm. preterm. BW 900g.Outcome  Live. singleton female delivered via NSD. HC 20cm. AS 8.

Course in the Wards .

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 2.01 Babygram Hazy infiltrates on both lung fields Hct 0.2 CBC Hgb 113 WBC 10.6 Neut 0.48 pCO2 32 MANAGEMENT NPO.51 Mono 0.2mkdose 16th hour of life Nasal SIMV FiO2 25% P/P 12/4 VR 20 IT 0.33 Plt 247 Lympho 0.5 PSV 2(6) .36 pO2 98 HCO3 18.Hx/PE At birth HR 160s RR 50s Acrocyanotic Thermoregulated (+) retractions LABORATORY ABG pH 7. IVF started NCPAP FiO2 25% O2FR 6 CA 5.7 O2 sat 97% PEEP 5 BE -5.

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poikilocytosis.10 DB 0.Hx/PE 24th hour of life HR 110 Jaundiced to chest O2 sat 58% (-) respiratory effort (+) jaundiced to chest LABORATORY CBC Hgb 115 WBC 7.30 IB 5.53 Eos 0. RBC anisocytosis.5 Retic ct 26 Hgt 195 CRP 1.80 IVF: D10  D5  D4 Na 137 K 3. EL 12-15 TB 6.91 PE 5-7.04 Hct 0.33 Plt 229 Lympho 0.3 Neut 0. platelet adequate VR 20 IT 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.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) .53 TCa 8.

2 HCO3 17.2 HCO3 17.53 Eos 0.9 pCO2 46.43 PNSS 9ml (10ml/kg) bolus Dobutamine (10µg/kg/min) started Increased dopamine (10µg/kg/min) FFP (10ml/kg) transfusion PRBC (10ml/kg) transfusion MV Settings 64th hour of life ABG pH 7.2 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 0.198 pO2 119.04 Hct 0.3 Neut 0.198 pO2 119.5 58th hour of life HR 170-180 Poor pulses CRT 2-3 secs Firm fontanelles CBC Hgb 115 WBC 7.5 .9 pCO2 46.1% BE -10.2 FiO2 30% P/P 10/5 PSV 2(7) VR 40 IT 0.2 O2 sat 97.Hx/PE 57th hour of life HR 190s RR 50 O2 sat 97-98% Thermoregulated Fair pulses CRT 3 secs LABORATORY ABG pH 7.2 O2 sat 97.1% BE -10.33 Plt 229 Lympho 0.

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 (12µg/kg/hr  15µg/kg/hr) HR 210 RR50s O2 sat 100% Fair pulses CRT 2 secs ABG PNSS 9ml (10ml/kg) bolus Epinephrine drip (0.1% BE -11.193 pO2 76.5. Level 6) MV Settings pH 7.3 O2 sat 91.0 pCO2 44.0 HCO3 17.1µg/kg/min) started Intubated (ET sz 2.1 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 .

5µg/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 0.2 MANAGEMENT MV Settings FiO2 40% P/P 10/3 PSV 0 VR 30 IT 0.4 pO2 146.5 .6 O2 sat 98.Hx/PE Day 4 of life HR 180s RR 50s-60s O2 sat 98% Thermoregulated Good pulses CRT <2secs LABORATORY ABG pH 7.2 pCO2 19.5 HCO3 12.5 Decrease epinephrine drip (0.8% BE -9.

E 1:11 Dobutamine  5mcg/kg/min IVIG #2 infusion (750mg/kg/dose) Extubated NCPAP FiO2 30% PEEP 5 O2 0.7 FFP transfusion 10ml/kg (+) 2 episodes of apnea (HR 50s.5 I. equal breath sounds Good pulses CRT <2secs LABORATORY MANAGEMENT MV Settings FiO2 25% P/P 8/3 PSV 0(3) VR 10 IT 0. CRT <2secs Shifted to nasal SIMV MV Settings FiO2 30% P/P 10/3 PSV 2(5) VR 20 IT 0.5 . irregular respirations) Improved after PPV Pulses full. O2 sat 80s.3 O2FR 6 CA 5.Hx/PE Day 5 of life HR 160s-170s RR 50s O2 sat 100% (+) recurrent hypothermia (-) retractions Clear.

5 pO2 75.5 CHEST XRAY Mild regression of previously noted infiltrates .4 Neut 0.3 MANAGEMENT Intubated ET sz 2.5 Level 6 MV Settings FiO2 25% VR 20 IT 0.7 TB 3.59 Eos 0.01 Phototherapy discontinued Na 140 K 4.Hx/PE Day 5 of life (+) recurrent apnea (HR 80s O2 sat 80s.8 HCO3 19.33 Plt 238 Lympho 0.04 O2 sat 93% P/P 10/3 BE -7 PSV 0 Hct 0.38 Tca 9.75 Crea 0.48 BUN 27.273 pCO2 42.8mkdose q8) Transfuse PRBC 10ml/kg Bands 0.01 Aminophylline increased (2. irregular respirations) Fontanelles soft LABORATORY ABG pH 7.91 ECC 12.6 IB 2.5 CBC Hgb 112 WBC 6.36 Mono 0.10 DB 0.

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70 DB 0.5 Day7 of life TB 10.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 0.40 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 .30 IB 10.

4 Neut 0.5 Na 136 K 4.43 Mono 0.Hx/PE Day 7 of life (+) recurrent apnea HR 69 O2 sat 69% (+) shallow respirations Good pulses.232 pO2 55.5 HCO3 16.42 Plt 287 Lympho 0.76 .5 Hct 0. soft fontanelles LABORATORY CBC Hgb 142 WBC 15.52 BE -10.03 MANAGEMENT Hold feeding MV Settings FiO2 30% P/P 16/5 PSV 2(7) VR 20 IT 0.02 ABG pH 7.45 TCa 9. CRT<2 secs.52 Eos 0.4 pCO2 39 O2sat 81.

5 HCO3 correction Phenobarbital (LD 10mkdose.5 Intubated (ET sz 2.5 ABG pH 7.1 IB 6. R axis.135 pO2 58.1 O2sat 93% BE -12. MD 3mkd) 6hrs post double photo TB 6.5 pCO2 41.3 HCO3 15.185 pO2 84.4 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 0.8 HCO3 18.7 DB 0.6 pCO2 55.5 Level 6) MV Settings (PCV mode) FiO2 60% P/P 12/4 VR 30 IT 0.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.3 O2sat 79% BE -11.6 Double phototherapy  single phototherapy . RVH normal for age ABG pH 7.

R Good pulses CRT <2secs LABORATORY CXR (PA.21 (-) Referred to Genetics A> t/c Inborn error of metabolism P> For expanded NBS.6 114.5 MV Settings (SIMV) FiO2 40% P/P 8/3 VR 25 IT 0. lat) Reexpansion of R lung (+) infiltrates at R lower lung field MV Settings (SIMV) FiO2 50% ABG (post HCO3 correction) pH 7.5 CXR (PA. R MANAGEMENT Needling done. urine organic acid analysis.Hx/PE Day 8 of life RR 40 (+) dusky (+) dec BS. lat) Large pneumothorax.9 pCO2 23.6 O2sat 98% BE -15.6 HCO3 9. 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 0.1-17.231 pO2 129.5 11.7 P/P 8/3 VR 30 IT 0.5 Serum Cl Anion gap Serum ammonia Urine ketones 108. urine metabolic panel Limit AA to 1g/kg/day .

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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%.5 HCO3 18.5 Decreased midazolam drip (0.04mg/kg/hr) Reload phenobarbital (10mkdose) Increase midazolam drip (0.8% BE -7 FiO2 40% P/P 8/3 I:E 1:2 VR 50 IT 0. MD 5.2mg/kg/hr) . tongue thrusting) LABORATORY MANAGEMENT Phenytoin (LD 19.9mkdose) For neonatal EEG Midazolam drip started (0.1mg/kg/hr  0.5 mkdose. HR 160s.2 pCO2 36.311 pO2 59.1mg/kg/hr) ABG MV Settings (PCV mode) pH 7. pallor.1 O2 sat 87.

7 Neut 0.18 Midazolam stat dose (0. no respiratory effort) ~20mins Hgb 103 WBC 18. HR 160s) LABORATORY MANAGEMENT Increased midazolam drip (0.80 Mono 0.02 Hct 0.07 ABG pH 7.Hx/PE Day 11 of life (+) recurrence of seizure (O2 desat 78%.5 Na 143 K 4.92 TCa 10.3 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. pallor.9 O2 sat 91.8 BE -6.9 D/c phenobarbital and phenytoin Start levetiracetam (10mkd) .15mg/kg/dose) Diazepam stat dose (0.33mg/kg/dose) MV Settings (PCV mode) FiO2 40% VR 30 IT 0. tongue thrusting.193 pO2 78 HCO3 23 pCO2 59.4mg/kg/hr) CBC (+) recurrence of seizure (O2 desat 70s.31 Plt 263 Lympho 0.

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5 Dobutamine (10mcg/kg/min) .169 pO2 51.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 7.3 pCO2 64.1 O2 sat 74% BE -6.6 HCO3 23. MD 30mg/kg/hr) MV Settings (PCV mode) FiO2 100% P/P 12/4 I:E 1:3 VR 60 IT 0.8 MANAGEMENT Dopamine started (10mcg/kg/min) MgSO4 (LD 200mg/kg.

15mkdose x2 Diazepam stat dose 0.5 HCO3 16.4% BE -7.1mg/kg/hr  0. tongue thrusting.3mkdose x2 Loaded levetiracetam 10mkdose Increase midazolam drip 0. dusky.Hx/PE Day 14 of life O2 sat 97-100% (preductal and postductal) Good chest rise LABORATORY ABG pH 7.2 MANAGEMENT MV Settings (PCV mode) FiO2 100% P/P 10/3 I:E 1:3 VR 40 IT 0.0 O2 sat 99.5 Decrease MgSO4 (15mg/kg/hr) then to consume Day 15 of life EEG Start pyridoxine (LD 100mg MD 50mg) Decrease midazolam 0. HR 160s.346 pO2 213.2mg/kg/hr Day 16 of life (+) recurrence of seizure ~1hr (O2 desat 72%.9 pCO2 31. no respiratory effort) .05mg/kg/hr Midazolam stat dose 0.

Thank You. .