MORTALITY

• Live, preterm, baby boy• Delivered via stat cesarean section due to

previous CS in labor• 40 yo G3P3 (2-1-0-3)• LMP 31 5/7 weeks; MT 33weeks AGA• APGAR score 9,9

BABY M

• 33 weeks• Appropriate for

gestational age• Birthweight: 1630 g• Birthlength: 41 cm• Head Circ: 28cm • Chest Circ: 25 cm• Abd Circ: 21 cm

MATERNAL HISTORY

• Regular prenatal check-up• (+) Chronic hypertension for 7 years maintained on

Methyldopamine 500mg every 6 hours during pregnancy• (+) Gestational diabetes at 20 weeks AOG advised diet modification• (+) UTI during the third trimester, took Cefalexin for 7 days

UPON ADMISSION

• CBC:

• UA: RBC 6 WBC 6 EC 11 Cast 0 Bacteria 38

Hgb Hct WBC Band Neut Lym Mon Plt

108 32 12 72 18 8 2 278

• Penicillin allergy• No asthma• No previous hospitalization except during past

pregnancies

PAST MEDICAL HISTORY

• Hypertension – maternal side• DM – maternal side

FAMILY HISTORY

• Nonsmoker• Non alcoholic beverage drinker

PERSONAL & SOCIAL HISTORY

• G1- 2006, PCS for failed indution in labor, fullterm, F, 6.5 lbs (GDM, HPN)

• G2- 2010, repeat CS, full term , M, 7.3lbs (GDM, HPN)

• G3-2013-PP

OB HISTORY

• Clear amniotic fluid• HR 150s

APGAR SCORE : 9,9

Upon delivery

ASSESSMENT:Live preterm baby boyDelivered via stat CS for repeat CS in labor at 31 5/7 weeks AOGApgar Score 9,9

ADMISSION

Management• Routine newborn care done• Admitted to NICU Level 3• NPO• O2 support via nasal canula• IVF started• Calcium gluconate started• Septic workup:

Blood CS: No growth in 72 hoursAmpicillin, Amikacin started

Hgb Hct WBC Band Neut Lym Mon Plt

188 56 13.6 35 57 06 02 186

Course in the NICU

1st Day of LifePROBLEMS

• Prematurity

• Probable sepsis

• Patient was placed in an isolette

• NPO• IV fluid continued• Hgt monitoring done

• Ampicillin, Amikacin continued

2nd Day of LifePROBLEMS

• Jaundice

• Apnea– O2 sat 86%– HR 100

• Nutritional buildup

• Phototherapy started

• Aminophylline started• Continue O2 support until

weaning

• Kept on NPO• Aminosteril started

3rd Day of LifePROBLEMS

• Vomiting of coffee ground material after feeding

• Kept on NPO• Vitamin K given

4th Day of LifePROBLEMS

• Nutritional buildup • Feeding with expressed breast milk was started

• Intralipid was started

6th Day of LifePROBLEMS

• Apnea– Less than 10 seconds– Improved by stimulation

• Cyanosis with hemodynamic compromise– HR <60, O2 sat 91%, RR 52,

SBP 32mmHg– Thready and variable pulses– Violaceous lower

extremities

• O2 support via nasal canula

• Resuscitation– Chest compression– Intubation – 2 doses of epinephrine– Fluid resuscitation– NaHCO3 given

• Septic Shock

– Blood CS• Gram (-) cocobacilli

after 9.12 hours• Acinetobacter

baumannii• Sensitive to: Amikacin,

Ceftazidime, Gentamycin, Ciprofloxcin, Levofloxacin, Pip-Taz, TMP-SMX

• Antibiotics shifted to Meropenem, Oxacillin and Metronidazole

• Dopamine drip started

Hgb Hct WBC Band Neut Lym Mon Plt

143 43 6 41 53 01 05 40

VBG Metabolic acidosis

pH 7.05

pCO2 42.5

pO2 37

HCO3 11.8

BE -19

SO2 48

• NaHCO3 given

VBG Metabolic acidosis

Metabolic acidosis

Metabolic acidosis

Metabolic acidosis

Metabolic &

Respiratory acidosis

pH 7.05 6.94 7.18 7.12 6.97

pCO2 42.5 47.1 21.5 43.30 61.4

pO2 37 29 43 24 26

HCO3 11.8 10.10 8.1 13.9 14

BE -19 -22 -20 -16 -18

SO2 48 27 68 26 24

• CXR

• Fine reticulonodular opacities seen throughout both lungs, predominantly in the inner lung zones

Impression: Consider bilateral pneumonia

• t/c DIC– Bleeding at the puncture

sites– Fresh blood draining at

the OGT– Purpura fulminans– Platelet count of 40,000

• Vitamin K• Famotidine• IVIG• Blood transfusion– Platelet concentrate – Fresh frozen plasma– Packed RBC (not given)

Hgb 122 112 82 75 61

Hct 36 33 24 22 18

• Acute renal failure– No urine output x 12

hours

• Fluid resuscitation• Furosemide

• Electrolyte imbalance • Calcium gluconate given

Na 144 148 149 147 144K 3.9 4 6.2 8 >9iCa 1.13 1 0.82 0.73 0.71

• Seizure (t/c Intraventricular Hemorrhage)

• Phenobarbital

7th Day of Life

• Desaturation despite bag tube ventilation• Bradycardia (HR 40s), Hypotension

(Undetectable)• Resuscitation with chest compression and

epinephrine • After 45 minutes of resuscitation, patient was

pronounced dead.• Postmortem care done.

FINAL DIAGNOSIS

• Prematurity• Septic shock secondary to Acinetobacter

baumannii• Disseminated Intravascular Coagulation• r/o Intraventricular Hemorrhage• Neonatal Pneumonia• Acute renal failure

Acinetobacter baumanniiThe most resistant of the genospecies and has the greatest clinical importance

• Naturally inhabits water and soil• Isolated from foods and arthropods • In humans, can colonize:– Skin, wounds– Respiratory– GI

• Can survive environmental dessication for weeks promotes transmission through fomite contamination in hospital

RISK FACTORS AMONG NEONATES

• Low birth weight• Total parenteral nutrition• Central venous catheters

Mittal N, Nair D, Gupta N, et al. Outbreak of Acinetobacter spp septicemia in a neonatal ICU. Southeast Asian J Trop Med Public Health 2003; 34:365.Huang YC, Su LH, Wu TL, et al. Outbreak of Acinetobacter baumannii bacteremia in a neonatal intensive care unit: clinical implications and genotyping analysis. Pediatr Infect Dis J 2002; 21:1105.

Health Care Associated Infection

• Acinetobacter outbreaks have been traced to: 1. common-source contamination (particularly

contaminated respiratory and ventilator equipment)

2. cross-infection by the hands of health care workers caring for colonized or infected patients

Hartstein AI, Rashad AL, Liebler JM, et al. Multiple intensive care unit outbreak of Acinetobacter calcoaceticus subspecies anitratus respiratory infection and colonization associated with contaminated, reusable ventilator circuits and resuscitation bags. Am J Med 1988; 85:624.Maragakis LL, Cosgrove SE, Song X, et al. An outbreak of multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment. JAMA 2004; 292:3006.

Bloodstream Infection

• Acinetobacter accounts for 1.5 to 2.4 percent of nosocomial bloodstream infections

• Most frequent source: vascular catheter , respiratory tract

• Less common: Wounds, urinary tract• Septic shock develops in up to one-third of

patients.

• Data regarding the prognosis of patients: limited• Patients usually have longer ICU stay, higher rate of

organ failure and higher mortality rates • Risk factors for mortality:– Imipinem resistence– ICU stay– Female gender– Old age– Pneumonia– Diabetes– Septic shock