Transcript Free Flow O2 Thermoregulation

CASE 1:
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R.R.G
39, G2P1 (0-1-0-1), 25 1/7 weeks
CC: watery vaginal discharge
Past Medical: G1 – NSD at 33 weeks AOG
Personal/Social History: U/R
Family History: (+) Hypertension, Asthma, Diabetes
Birth History
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Baby Boy
Live, preterm
Delivered via Normal Spontaneous Delivery
39 y/o (G2P2) (0202)
25 4/7 weeks AOG
MT: 26 weeks, AGA
Anthropometrics
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BW 830g
BL 32 cm
HC 24 cm
CC 21 cm
AC 18
APGAR SCORE (1st minute) = 3
SIGN
Heart rate
Respiratory
effort
Muscle
tone
0
Absent
Absent
Limp
1
Below 100
Slow,
irregular
Some
flexion of
extremities
Grimace
Response No
to catheter response
in nostril
(tested
after
oropharynx
is clear)
Color
Blue, pale Body pink,
extremities
blue
2
Over 100
Good,
crying
Active
motion
Cough or
sneeze
Completely
pink
Positive
Pressure
Ventilation
APGAR SCORE (5th minute) = 6
SIGN
Heart rate
Respiratory
effort
Muscle
tone
0
Absent
Absent
Limp
1
Below 100
Slow,
irregular
Some
flexion of
extremities
Grimace
Response No
to catheter response
in nostril
(tested
after
oropharynx
is clear)
Color
Blue, pale Body pink,
extremities
blue
2
Over 100
Good,
crying
Active
motion
Cough or
sneeze
Completely
pink
Positive
Pressure
Ventilation
APGAR SCORE (10th minute) = 7
SIGN
Heart rate
Respiratory
effort
Muscle
tone
0
Absent
Absent
Limp
1
Below 100
Slow,
irregular
Some
flexion of
extremities
Grimace
Response No
to catheter response
in nostril
(tested
after
oropharynx
is clear)
Color
Blue, pale Body pink,
extremities
blue
2
Over 100
Good,
crying
Active
motion
Cough or
sneeze
Completely
pink
Free Flow O2
Thermoregulation
Admitting Impression
• Extreme Prematurity, Very Low Birth Weight
Sepsis Unspecified
• UVC inserted
• O2 support via nasal cannula at 2 lpm
• Diagnostics:
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CBC, CRP
Blood Culture
Hgt
CXR
• Therapeutics:
– IVF at TFR 80
– IV antibiotics (Ampicillin, Amikacin)
– Aminophylline
PROBLEMS
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1. Prematurity
2. Sepsis
3.. Respiratory (Pneumonia and Apnea)
4. Jaundice
5. Anemia
Problem 1: Prematurity
• Thermoregulation:
– The patient was placed in an isollette and
wrapped in plastic to keep thermoregulated.
– Temperature maintained at 36.5-37.5C
• Feedings:
– Upon delivery patient was on NPO, IVF started at
TFR 80
– Aminosteril started
– On the 3rd day of life, NGT was inserted and
patient was started on Glucose water then Breast
milk
Problem 2: Sepsis
• Diagnostics:
– CBC
– CRP
– Blood culture
• Patient was started on the following
medications:
– Ampicillin
– Amikacin
Hgb Hct
WBC Band Neu Lym
Mon
Eos Plt
116 35
19
02
6
2
CRP 0.04
Blood Culture: No growth (7 days)
80
16
261
Problem 3: Respiratory
• Pneumonia in the
left lower lung
• UVC at level of T7 to
T8
Start Cefotaxime
Problem 3. Respiratory (Apnea)
First hour of life
Awake
Active
No desaturations
T 37 HR 130 RR
49 O2 sats 97
Generalized
Jaundice
No alar flaring
Good air entry
Harsh breath
sounds
Regular cardiac
rhythm
Full pulses
Prematurity
Sepsis Unspecified
Start
Aminophylline
2nd day of life
Awake
Active
Episodes of
desaturations and
bradycardia
T 37
HR Less than 100
O2 sats 70s
Generalized
Jaundice
No alar flaring
Good air entry
Harsh breath
sounds
Regular cardiac
rhythm
Full pulses
Apnea of
Prematurity
Continue
Aminophylline
Stimulation during
periods of apnea
11th day of life
Awake
Active
Persistent
desaturations
T 37C
HR less than 100
O2 sats 40s-50s
Pink
Minimal effort
on respiration
No alar flaring
sounds
Regular cardiac
rhythm
Full pulses
Apnea Probably
secondary to
progressing
Pneumonia or
Electrolyte
Imbalance
Ambubagging
EG7
Chest Xray
O2 support
pH
7.198
pCO2
74.4
pO2
80
HCO3
29
BE
1
SO2
92
Na
119
K
4.7
Ical
133
Hgb
82
Hct
24
Na correction
with NaCl
incorporation
• Progressing
Pneumonia with
Consolidation
11th day of life
Awake
Active
Persistent
desaturations
T 37C
HR less than 100
O2 sats 40s-50s
Pink
Minimal effort
on respiration
No alar flaring
sounds
Regular cardiac
rhythm
Full pulses
Apnea Probably
secondary to
progressing
Pneumonia or
Electrolyte
Imbalance
For intubation
Mech Vent
settings:
FiO2 60
PIP 18
PEEP 4
RR 50
iT 0.45
Repeat CBC and
EG7
Shift IV
antibiotics to
Meropenem
pH
7.387
Hgb
91
pCO2
32.3
Hct
27
pO2
42.9
WBC
14.6
HCO3
19.4
Neutrophils
70
BE
Lymphocytes
23
SO2
Monocytes
2
Eosinophils
0
Platelet
422
Cranial Ultrasound
• Intraventricular and Germinal Matrix
Hemorrhage (Grade II intracranial
hemorrhage)
13th to 17th day of life
Awake
Active
Episodes of
desaturation
T 37C
HR 130
O2 sats 95-100%
Pink
Minimal effort
on respiration
No alar flaring
sounds
Regular cardiac
rhythm
Full pulses
t/c
Bronchopulmonary
Dysplasia
Mech Vent
settings adjusted
accordingly
Start
Dexamethasone
Problem 4: Jaundice
2nd day of life
Awake
Active
No
desaturations
T 37.1 HR 140 RR
49 O2 sats 96
Generalized
Jaundice
No alar flaring
Good air entry
Harsh breath
sounds
Regular cardiac
rhythm
Full pulses
Prematurity
Sepsis Unspecified
Hyperbilirubinemia
Unspecified
Start double
phototherapy
Problem 4: Jaundice
4th day
Awake
Active
T 37
HR 130
RR 50
O2 sats 98
Pink
No alar flaring
Good air entry
Harsh breath
sounds
Regular cardiac
rhythm
Full pulses
Prematurity
Sepsis Unspecified
Hyperbilirubinemia
Unspecified,
resolved
Phototherapy
discontinued
Problem 6: Anemia
12th day of life
T 36.5 HR 150 RR
53 O2 sats 95
Pale skin
No alar flaring
Harsh breath
sounds
Regular cardiac
rhythm
Full pulses
Prematurity
Sepsis Unspecified
Apnea of
Prematurity
Anemia
PRBC for
transfusion
Pre
transfusion
Hgb
Hct
82
24
Hgb
Hct
Post
127
Transfusion
37
• Diagnosis:
• Extreme Prematurity, Very Low Birth Weight,
Sepsis Unspecified, Neonatal Pneumonia,
Apnea of Prematurity, t/c Bronchopulmonary
Dysplasia
•THANK YOU