One of lectures given during our Port said fifth neonatology conference, 23-24 October 2014 given by dr Dr El Sayed Khalaf MD Pediatrics,Consultant Pediatric and Neonatology

1. Port-Foad NICU
Dr El Sayed Khalaf
MD Pediatric
Consultant Pediatric and Neonatology

2. CASE STUDY

3. Admission data
• Female Preterm Baby ± 28 W GA
• Accidental Vaginal delivery in Taxi.
• Admitted to our NICU first day of age referred
from other hospital.
• Family H: brother with CP 6y, and good sister 8y.
• O/E:
– Very Bad general condition.
– Hypothermic BP:35/25.
– BW:900 gm
– HC:24 cm.
– Cyanosed, Weak pulses.
– Chest : RD grade IV, diminished bilateral air entry.
– O2 sat:70-80%

4. • Cardiac exam:
– HR:160/Min, no MM or thrill.
– Delayed capillary refill time
• Abdominal exam:
• Abd. circum: 18.5 cm
• No distension – No Organomegally
• Normal Umbilicus.
– Neurological Exam:
• Weak Reflexes,
• No convulsions, lethargic, hypotonic.
– Ecchymotic patches on both LL.

5. • Investigations:
– CBC:HB:15gm/dl,HCT:46%,
– Plt:132,WBC:10.3.
– CRP: -ve
– RBS: 118mg/dl
– Chest X-Ray: White lungs.
– ABG:
• PH7.2,PCO2:57,PO2:33,Hco3:15.

6. Management
• Incubator Care.
• IVF: Glucose 5-7.5%, 90ml/Kg.
• Inotropics: Dopamine, Dobutamine Infusion.
• Prophylactic Phototherapy.
• Started ET intubation immediately.
• Mechanical Ventilation A/C.
• NPO.
• Vit K1 1mg.

7. • Surfactant adminstration (Survanta) 2.5 ml
Endotracheal.
• Antibiotics: Cefepim, amp-sulbactam
• Ventilator Setting:
– Fio2: 40%,PEEP:4,PIP:10,Rate:50/m,Ti:0.3 sec
– O2 sat:92% by pulse Oxy.
• Blood gases after 2 hours:
– PH:7.21, PCO2:47, PO2:55, Hco3:19.

8. Day 2
• Bad general Condition.
• Air entry bilateral is deminished
• Convulsions started: Generalized tonic clonic,
Baby desaturated, Pale with skin mottling .
• No urine output.
• RBS: 146 mg.
• HB: 5.6 gm/dl, Plt:112, WBC:9.9, Retics: 6%.
• ABG: PH 7.25, PCO2: 35, PO2: 85, Hco3: 11.6 mEq.
• Vent Setting:
– Fio2: 75%, PEEP: 5, PIP:19, Rate: 50/M, Ti: 0.3sec,
– O2 sat:90%

9. Management
• Anticonvulasnts Started:
– Phenobarbitone: Loading and maintenance dose.
– Phenytoin : Loading and maintenance dose.
• Packed RBCs transfusion 10 ml/kg, (Twice).
• Inotrops continued.
• Sedation by edazolam Infusion.
• TPN started: Total fluid:100ml/Kg, Pt 1gm/kg,
Lipids 0.5gm/kg, MV, Glucose infusion,,
GIR:5mg/kg/min.
• Ca gluconate infusion:2ml/kg.
• Platelets transfusion 10 ml/kg.
• Vit K IV 2mg/Dose.
• Furosemide 1mg/dose.

10. Day 3 - 4
• Still baby unstable, mottled, convulsions stop.
• Chest: On MV, fair bilateral air entry.
• Pulses average volume, 155/min.
• Abdomen: soft, lax and no distension.
• ABG:PH7.22,PCO2:45,PO2:98,Hco3:19 mEq.
• Invest:
– S Cr:0.88,Urea:72, S GPT:23,GOT:146, T Pt:4.7,
Alb:3 gm.
– HB:13.7, WBC:9.9, Lymp:52%.Neutro:39%, Plt:80.
– CRP : -ve, TS bil:12mg, D:1mg
– Bl sugar:153 – 285mg/dl after insulin infusion.

11. • Trophic feeding started 1ml/6h diluted formula or
breast milk.
• Platelet trasnsfusion.
• Intensive phototherapy.
• Still on TPN: Lipid, Pts, CHO, MV and electrolytes.
• IV Ca gluc 10%.
• Continuous insulin infusion with monitoring of blood
glucose.

12. Day 5
• Serial measurement of serum bilirubin get low
down to TSB:6.7mg/dl, D:0.90mg/dl.
• Baby general condition became more stable.
• Tolerate trophic feeding by NGT 1ml /4h diluted
formula.
• HB:13 gm/dl, Plt:156. WBC:21, CRP 6mg, S Cr:1.78,
GPT:30, GOT:75, Alb:3.5 gm.
• ABG:PH 7.35, PCO2:42, PO2:95, Hco3:19.6 mEq.
• Vent setting:
– Fio2: 21%, PEEP:5, PIP:15, Rate:40/min, Ti: 0.25 sec,
O2 sat:95%

14. Day 6-11
• Abd distension, abd circumference 20 cm, bluish
discoloration of abd wall.
– Greenish discharge from NG tube.
– Diminished intestinal sounds and not passing stools.
– No organomegally, no ascites.
• Attacks of desaturation and skin mottling.
• Poor activity, generalized hypotonia.
• No dehydration, BW:820 gm, HC:24.5cm
• Pulses: very weak, BP 44/20 (M32), Delayed
capillary refill time
• Decrease urine output.
• NEC is suspected

15. • Stop feeding.
• Abdomen X-Ray:
– Dilated intestinal loops, No Air under diaphragm, no
air fluid levels.
• Na: 135mEq, K: 3 mEq.
• S Cr:1.6, Urea:123, S GPT:15, GOT:56, triglycerides
129, CRP 1.9mg, RBS ranges 128-350mg/dl.
• ABG:PH: 7.36, PCO2: 44, PO2: 98, Hco3: 25 mEq.
• Vent setting no critical changes.
• Open NG tube, Add metronidazole infusion, Inotropics,
restart insulin infusion& fluconazol infusion.
• TPN:
– Pt:1.5-2gm, Lipids:1-1.5gm, GIR:7-8.5mg/kg/min.
– Na: 2-3meq, fat and water soluble vitamins and trace
elements.

16. D 12
• Baby still has marked abd distension.
• Greenish discharge from NG tube.
• Suddenly the baby get severe RD, cyanosis,
diminished air entry on Lt side with shift of
mediastinum to the Rt side.
• Baby has severe shock.
• Urgent chest X-ray shows Lt sided tension
pneumothorax.
• ABG:PH: 7.21, PCO2:58, PO2:42, Hco3:15 mEq.
• HB:12 gm/dl, RBC:4.2/CC, Plt:91. WBC:11, CRP:21mg,
S GPT:32,GOT:48,
• Na:122 mEq, K:3 mEq, Cr:0.8, Urea:58.

17. • Urgent chest decompression by intercostal
cannula
• Chest tube placement.
• Inotropics.
• Vent setting:
– Fio2: 40%, PEEP:4, PIP:9 , Rate:60/m,Ti:0.25 sec, O2
sat:92%.
• Still NPO.
• Full TPN.
• Na deficit is corrected.
• Change antibiotics to: Targocid and Ceftazidim

19. D 15-22
• Baby general condition improved.
• BW:820 gm
• Air entry audible bilateral.
• Less abd distension (abd circum 19.5).
• Less NGT secretion and pass stool.
• More active, HC 26.5, fontanell became tense,
and skull sutures more wide.
• CRP: -ve
• HB:12 gm/dl, RBC:3.9/CC, Plt:115. WBC:16,
GPT: 57, GOT:48, Na:132 mEq, K:4 mEq,
Cr:0.6, Urea:58.

21. • Removal of the Chest tube.
• Serial measurement of head circumference and
abdominal circuference.
• Still NPO, full TPN.
• Phenobarbitone still.
• We start IV steroids for 3 days.
• Change to CPAP.
• Then extubation and Nasal CPAP Fio2: 21 -30%.
• With frequent chest physiotherapy
• Same antibiotics.
• Caffeine citrate IV.
• Plan for MRI of the Brain and skull.

23. D 23-30
• Baby became more stable. BW: 840-880 gm
• No convulsions or abd distension =18 cm.
• Complete 14 days NPO.
• No RD, Off NCPAP.
• Head circumference: 27.5, Fontanelle more tense,
baby more active.
• HB:11gm, triglycerides:69mg/dl,Na:131,K:4
• S Cr: 0.8mg/dl.
• Liver function tests: Normal values.
• Neurosurgical consultation.

25. • NGT feeding started 1ml/4h breast milk.
• Feeding increased gradually up to 10ml/3h full
concentration premature formula and breast
milk by syring pump over 1 hour.
• Head box.
• TPN decreased gradually.
• MRI Shows: Dilated lateral and 3rd ventricles,
IVH.
• Phenobarbitone still continued 4mg/kg/day.

27. D 30-45
• Serial measurements of head circumference:
30cm, Fontanelles are tense, baby is active, mild
hypotonia and no convulsions.
• Tolerate NGT feeding and started oral suckling
• Weight gain is satisfactory 1.250 kg.
• Repeated neurosurgical consultation advised
follow up.
• Auditory function eaxam was normal.
• Fundus exam not available.
• CRP: -ve, HB:11gm.
• Folic acid and oral phenobarbitone.

28. Up to day 56
• Baby discharged BW 1450 kg below 3rd
centile for age.
• Head circumference 31.5 cm, 25th centile
• Full oral intake by suckling.
• Neurological exam is satisfactory.
• Intact reflexes.
• Referred for neurosurgical consultation for
follow up and fundus exam.

29. After 2months of discharge
(3.15 months)
• BW: 3.5 kg. 10th centile,
• L: 46 cm, below 3rd centile.
• Head circuference: 36 cm 25th centile.
• Mild hyper-reflexia.
• Oral suckling is good.
• Head support and turning in bed.
• Brain MRI: Mild dilatation brain ventricles.

30. Growth Curves for Prematures

32. MRI after 1 M of discharge

35. Thank You