WEDNESDAY NIGHT SHIFT REPORT

1
January 16, 2019

DR. AMA/ DR. ATA/ DR. CHANDRA/DR. LABIQ/ DR. IDA/ DR. INDRA
DR. LUBNA/ DR. IRIZ
DR. DELFIA
 LIST OF PATIENT
ADMISSION

• Neonatal ICU
• Baby of Mrs. S, 0 day old, 1600 grams, with moderate asphyxia,
severe respiratory disorder due to congenital pneumonia dd
HMD, mild hypothermia, neonatal infection; neonates, male,
low birth weight, small for gestational age, preterm, caesarean
section due to severe preeclampsia impending eclampsia,
partial HELLP syndrome, leukocytosis mother
• Neonatal HCU (-)
• Pediatric HCU (-)
• PICU (-)
• Melati 2 (-)
• Melati 3 (-)
 PATIENT IDENTITY

Name : Baby of Mrs. S

Age/weight : 0 days old/1600 gram
Gender : male
Address : Wonogiri
MR number : 01446792
Admission : January 16, 2019
CHIEF COMPLAINT:
Did not cry vigorously after birth

A male infant patient was born from G4 P1 A2, 32 year old

mother by caesarian section due to severe preeclampsia
impending eclampsia, partial HELLP syndrome, and
leukocytosis. The gestational age was 32 week. Shortly after
birth, the baby did not cry vigorously, didn’t show any active
movements directly, not spontaneously opened his eyes,
cyanotic episode with Apgar score 3-6-7-8, birthweight was
1600 grams, length was 41 cm, head circumference 30 cm,
chest circumference 27 cm, upper arm circumference 8 cm,
anus(+), meconium (-), clear amniotic fluid.
 ANAMNESIS

HISTORY OF PREGNANCY AND

LABOR
PREGNANCY
His mother is 32 years old, this was her fourth pregnancy, gestational age
was 32 weeks, antenatal care was routine in private hospital at Wonogiri
every month, mother denied any kind of illness during her pregnancy, never
been hospitalized. She had done 4 times ultrasonography during her
pregnancies. She has history of abortion for twice.

LABOR
Patient was born by caesarian section due to impending partial severe
preeclampsia, HELLP syndrome, mother with anemia and leukocytosis.
Patient did not cry vigorously, didn’t show any active movements directly, not
spontaneously opened his eyes, cyanotic episode with Apgar score 3-6-7-8,
birthweight was 1600 grams, length was 41 cm.

Conclusion
History of pregnancy was normal
5 and delivery was abnormal
HISTORY OF IMMUNIZATION

Patient had not been received any

immunization yet

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 ESSENTIAL NEONATAL CARE

Keep warm
Vitamin K1 1mg IM
Cutted umbilical cord and umbilical cord care
Prevent for eyes infection with gentamycin eye
ointment
Patient identity
Physical examination
 Pedigree

II

III

Baby of Mrs. S, 0
day old, 1600
grams
 PHYSICAL EXAMINATION
Issues Neonatal infection
CNS cry vigorously(-), HC = 30 centimeters
Active movements (-)
Spontaneously opened eyes (-)
Assessment: S3
CV system Heart rate : 16o bpm
Murmur (-), capillary refill time < 3’ , DPA strong palpable
Assessment: within normal limit
Respiration Respiration rate: 40 bpm
system Chest retraction (+) Cyanotic (-)
Air entry (-) Grunting (+), nasal flare (+)
Assessment : Downe score 4, moderate breathing disorder

GIT system Meconium (-) bowel sound (+), feces (-) vomitus (-), icterus (-)
Assessment : cannot be evaluated yet

Genitourinary Urine output (-)

system Assessment: cannot be evaluated yet

State of Thermoregulation status (36,00C ) GIT system : no Assessment: neonatal

infection CNS (+) S5 abnormalities found infection
CV system (-)
Respiration system : (+)

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 LABORATORY FINDING
January 16, 2019

Value Reference Units

Hemoglobin 14.5 11.5-15.5 g/dl
Hematocrit 44 35-45 %
Leucocyte 10.4 4.5-14.5 x103/ul
Thrombocyte 260 150-450 x103/ul
Erythrocyte 3.97 4.00-5.20 x106/ul
MCV 111.1 80.0-96.0 /um
MCH 36.5 28.0-33.0 pg
MCHC 32.9 33.0-36.0 g/dl
Neutrophil 12.1 29.00-72.00 %
Lymphocyte 39.20 30.00-48.00 %
Monocyte 5.00 0.00-5.00 %
Eosinophil 1.80 1.00-4.00 %
Basophil 0.70 0.00-1.00 %

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 LABORATORY FINDING
January 16, 2019

Value Reference Units

Sodium 130 132-145 mmol/L

Potassium 5.0 3.1-5.1 mmol/L
Calcium 1.23 1.17-1.29 mmol/L
Blood sugar 41 60-100 Mg/dl

CONCLUSION: within normal limits

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BW 1600 grams
BL 41 cms
Head circumference 30 cm

P10 < BW < P50 (normoweight)

P10 < BL < P50 (normoheight)
P50 < head circumference < P90
(normocephal)
 Ballad Score

Score neuromuscular maturity=20, Score physical

maturity=15
Total Ballad score : 20 ( maturity rating 32 weeks)
 LIST OF PROBLEM

Neonate, boy, 0 day, 1600 gram with:

 Born from caesarian section
 Cried not vigorously, did not active movement, eyes didn’t open
spontaneously
 Body weight 1600 gram, length 41 cm
 Small for gestational age
 Multipara
 Apgar score: 3-6-7-8
 Breath not spontaneously
 Not yellowish, no cyanotic
 Moderate respiratory distress, mild hypothermia
 Differential diagnoses

1. Moderate asphyxia neonates

2. Severe respiratory disorder due to congenital
pneumonia dd HMD
3. Neonatal infection
4. Mild hypothermia
5. Neonates, male, low birth weight, small for
gestational age, preterm, caesarean section due to
severe preeclampsia impending eclampsia , partial
HELLP syndrome, and leukocytosis mother
 Working Diagnose

1. Moderate asphyxia neonates (P21.1)

2. Severe respiratory disorder due to congenital
pneumonia dd HMD (R06.03)
3. Neonatal infection (P36)
4. Mild hypothermia (R68.0)
5. Neonates, male, low birth weight, small for
gestational age, preterm, caesarean section due to
severe preeclampsia impending eclampsia , partial
HELLP syndrome, and leukocytosis mother
 THERAPY

1. Admitted to NICU
1. First minute : bradycardia 20-30 minutes  oxygenation, CPR : VTP (3 : 1)
2. Second minute : bradycardia 40-50 minutes  CPR : VTP (3 : 1)
3. Third minute : heart rate 120x/ minute
2. NIV modus AC/PC, RR 40x/ minute, PEEP 5, Delta P 5, FiO2 40%
3. IVFD D10% 5.3 ml/h (GIR 5)
4. Ampicillin sulbactam (50 mg/kg/12h)= 80 mg/ 12 h IV
5. Gentamycin (7mg/kg/loading) = 11 mg  (5mg/kg/24h) = 8 mg/24 h IV
6. Aminophylline (6 mg/kg/loading) = 10 mg  (3 mg/kg/8h) = 5 mg/8 h
IV
7. Breast feeding/ milk on demand
8. Vit K 1 mg IM
9. Gentamicin eye ointment ODS
 PLANNING:

• Septic work up, CBC, blood smear, IT ratio, blood type,

electrolytes, blood culture
 Monitoring

General Appearance/ Vital sign/SiO2/ hours

Fluid and Balance and diutretic/ 8 hours
FOLLOW UP
17/01/19
 PHYSICAL EXAMINATION
Issues Neonatal infection
CNS cry vigorously(-), HC = 30 centimeters
Active movements (-)
Spontaneously opened eyes (-)
Assessment: S3
CV system Heart rate : 16o bpm
Murmur (-), capillary refill time < 3’ , DPA strong palpable
Assessment: within normal limit
Respiration Respiration rate: 40 bpm
system Chest retraction (+) Cyanotic (-)
Air entry (-) Grunting (+), nasal flare (+)
Assessment : Downe score 4, moderate breathing disorder

GIT system Meconium (-) bowel sound (+), feces (-)vomitus (-), icterus (-)
Assessment : cannot be evaluated yet

Genitourinary Urine output (-)

system Assessment: cannot be evaluated yet

State of Thermoregulation status (36,00C ) GIT system : no Assessment: neonatal

infection CNS (+) S5 abnormalities found infection
CV system (-)
Respiration system : (+)

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 LIST OF PROBLEM

Neonate, boy, 0 day, 1600 gram with:

 Born from caesarian section
 Cried not vigorously, did not active movement, eyes didn’t open
spontaneously
 Body weight 1600 gram, length 41 cm
 Small for gestational age
 Multipara
 Apgar score: 6-7-8
 Breath not spontaneously
 Not yellowish, no cyanotic
 Moderate respiratory distress, mild hypothermia
 Working Diagnose

1. Moderate asphyxia neonates (P21.1)

2. Severe respiratory disorder due to congenital
pneumonia dd HMD (R06.03)
3. Neonatal infection (P36)
4. Mild hypothermia (R68.0)
5. Neonates, male, low birth weight, small for
gestational age, preterm, caesarean section due to
severe preeclampsia impending eclampsia , partial
HELLP syndrome, and leukocytosis mother
 THERAPY

1. NIV modus AC/PC, RR 40x/ minute, PEEP 5, Delta P 5,

FiO2 40%
2. IVFD D10% 5.3 ml/h (GIR 5)
3. Ampicillin sulbactam (50 mg/kg/12h)= 80 mg/ 12 h IV
4. Gentamycin (7mg/kg/loading) = 11 mg 
(5mg/kg/24h) = 8 mg/24 h IV
5. Aminophylline (6 mg/kg/loading) = 10 mg  (3
mg/kg/8h) = 5 mg/8 h IV
6. Breast feeding/ milk on demand
7. Vit K 1 mg IM
8. Gentamicin eye ointment ODS
 PLANNING:

• IT ratio, blood culture waiting results

 Monitoring

General Appearance/ Vital sign/SiO2/ hours

Fluid and Balance and diutretic/ 8 hours
 What we should do if we help very low
birth weight baby ? Is it early CPAP usefull
?
• Very low birth weight baby
P
• Early CPAP
I
• Mechanical ventilation
C
• outcome
O
 VALIDITY
Was the defined representative
sample of patients asembled at
a common point in the course
of disease ?
• Yes

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Was patient follow up
sufficiently long and
complete ?
• No.
• It was retrospective study, so
they did not follow up the
subjectsWere outcome criteria either
objective or aplied in a “blind”
fashion ?
• Not mentioned in the journal
32
 IMPORTANC
E
What are the results ?

33
 APPLICABILIT
Y
Can i apply this journal to my
patient ?
• Yes
• Early CPAP was available in our hospital

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 Level of evidence
35

IMPORTA
NT

Not
3B APPLICA
APPLICA
VALID BLE
Thank you
Alur Resusitasi Neonatus IDAI 2017
Alur Resusitasi Neonatus IDAI 2017
 Ressusitation-after
virbhaa

Newborn baby : not crying vigourously

Initial step :
keep warm ( baby above the infant
warmer)
Keep the position
Clear the airway
Dry and clean it

Spontaneusly breathing (-), HR

100 x/ minute.
Tonus (weakness)
 Ressusitation
Positive ventilation pressure 40-60 x/minute, saturation 60%

Spontaneusly breathing(+)
Bad tonus
Saturation 60%

Spontaneusly breathing (+)

HR > 100 x/ minute.
Tonus (good)

CPAP, PEEP 6 cmH2o fiO

 Ressusitation
Positive ventilation pressure 40-60 x/minute, saturation 60%

Spontaneusly breathing(+)
Bad tonus
Saturation 90%

keep CPAP
PEEP 6-8 cm

The baby was stalel