NICU AUDIT

NICU AUDIT

February 2014

JPB

• Born on February 14, 2014• Live preterm baby girl• Delivered via Scheduled Primary Cesarean

Section for Maternal Condition (Breast Cancer)

• 41 y/o• G2P2 (1102) • 28 5/7 weeks AOG

Anthropometrics

• BW 1250 g• BL 38 cm• HC 26 cm• CC 23 cm• AC 21 cm• MT 30, AGA• AS 9,9

Maternal History

• Chronic hypertensive for 24 years, usual BP 140-150 systolic

• Feb 11, 2014- admitted at IMU for increase in BP given Methyldopa and Dexamethasone 10 mg every 12 hrs for 2 doses

Past Medical History• Feb. 2013

– noted to have a 2x3 cm mass on the left breast. – Mammography done showing “malignancy” but was lost to ff-

up• Feb. 3, 2014

– Breast mass was increasing in size w/ engorgement of the breast– Biopsy done w/c showed Intraductal Carcinoma of the Left

Breast, BIRADS 4• Feb 12, 2014

– Ultrasound done: BPS 8/8, EFW 1305 g, Placenta anterior, grade 2, high lying, normohydramnios, Myoma 2.5X2.6 cm

Family History

• DM• HTN

Personal/ Social History• unremarkable

OB History

• G1- 2008, NSD, Full Term, male, BW 8lbs• G2- present pregnancy

Delivery

• Apgar 1 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing

• Apgar 5 min: HR >120’s, acrocyanotic, good cry and activity, spontaneous breathing

• Immediately placed in a food grade plastic bag• O2 saturation: >85%• Newborn care was rendered

2nd Hour of lifeSubjective Objective Assessment Plan

•Grunting•Spontaneous breathing•No cyanosis

20 minutes after•No improvement of the grunting

•RR 60•Fair air entry•Subcostal, intercostal and suprasternal retraction

T/C Respiratory Distress Syndrome, Prematurity

•Hook to nasal CPAP•Oxacillin, Cefotaxime, Amikacin

•Intubation done•Surfactant therapy (4ml) given•Umbilical catheterization

VBG

pH pCO2 PO2 HCO3 O2 BE

7.328 61.7 45.1 32.3 76.3 5.3 Compensated Respiratory Acidosis

Chest Xray Consider Hyaline Membrane Disease, cannot totally rule out Neonatal Pnemonia

Blood Culture

No Growth (7 days)

CBC

Hgb Hct WBC Band Neu Lymp Mon Eos Plt

151 45 7.9 4 48 42 5 1 239 4nRBC/100 WBC

HGT 82

1st day of lifeSubjective Objective Assessment Plan

•Intubated•FiO2 40%•RR 35•PIP 14•PEEP 3.8•s/p surfactant therapy•Mother had a would culture: Heavy growth of S. aureus: sensitive to all except Penicillin

•VS: HR 144, RR 65, T 36.9 O2 sat 98%•Jaundice to upper chest•Good air entry, subcostal, intercostal, suprasternal retractions •Good cardiac tone•Soft abdomen•Full pulses

Respiratory Distress Syndrome vs Neonatal Pneumonia, Sepsis, unspecified, Hyperbilirubinemia, unspecified

•Labs: Bilirubin Levels, CRP, Chest Xray, Hgt

•Single Overhead Phototherapy

•Oxacillin, Cefotaxime, Amikacin

Bilirubin Levels

Total Direct Indirect

5.21 0.38 4.92

Chest Xray Consider Hyaline Membrane Disease, with interval improvement in the Lung Status

CRP 0.21 mg/dl

HGT 152

VBG



2nd day of lifeSubjective Objective Assessment Plan

•IntubatedFiO2 40%RR 40PIP 12PEEP 4iT 0.4 FR 10

•VS: HR 159, RR 63, T 37 O2 sat 100%•Jaundice to abdomen•Good air entry, suprasternal, subcostal, intercostal retractions •Good cardiac tone•Soft abdomen•Full pulses

Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemia, unspecified

•Labs: VBG, Na, K, Hgt


•Started feedings

•TPN started•Oxacillin, Cefotaxime, Amikacin

VBG



Na K

139 5.3

HGT 137

3rd day of lifeSubjective Objective Assessment Plan

•IntubatedFiO2 40%RR 35PIP 12PEEP 4iT 0. 4 FR 10

•VS: HR 159, RR 63, T 37 O2 sat 100%•Jaundice to face•Good air entry, subcostal, intercostal retractions •Good cardiac tone•Soft abdomen•Full pulses


•Labs: Hgt (123)



4th day of lifeSubjective Objective Assessment Plan

•Extubated•Shifted to nasal IPPVFiO2 30%PIP 12/4RR 15iT 0.4FR 8

•VS: HR 178, RR 68, T 36.8 O2 sat 100%•Jaundice to face•Good air entry, subcostal, retractions •Good cardiac tone•Soft abdomen•Full pulses


•Labs: Hgt (119)


•Epinephrine 0.1 ml + 1.5 ml NSS every 30 mins for 2 doses•Aminophylline 6 mg loading dose (4.8mg/kg), 1 mg every 12 hrs (0.8 mg/kg)•Oxacillin,Cefotaxime, Amikacin


•No desaturations•No cyanosis

•VS: HR 177, RR 50, T 36.8 O2 sat 100%•Jaundice to abdomen•Good air entry, subcostal, retractions •Good cardiac tone•Soft abdomen•Full pulses


•Labs: Hgt, Bilirubin level, Na, K


•Shifted to nasal cannula at 0.5 lpm, then discontinued


Bilirubin Levels


8.06 0.45 7.75 LRZ

Na K

132 6.3

HGT 87


•No desaturations•No cyanosis•apnea 5-10 seconds, HR 90’s, O2 sats 64-69%

•VS: HR 152, RR 67, T 36.6 O2 sat 98%•Jaundice to abdomen•Good air entry, no retractions•Good cardiac tone•Soft abdomen•Full pulses

Apnea, Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemia, unspecified

•Labs: CBC, hgt, Chest Xray

•Single Overhead Phototherapy (intermittent)

•O2 support discontined•Aminophylline increased to 2 mg IV (1.6 mg/kg)•Antibiotics shifted to Piperacillin- Tazobactam 60 mg IV (53 mg/kg/dose)

• CBC, hgt, chest xray

Chest Xray Hyaline Membrane Disease with further improvement in lung status

CBC


150 45 22 9 61 22 7 1 370 Slight toxic granules

HGT 68


•No desaturations•No cyanosis•No recurrence of apnea

•VS: HR 147, RR 48, T 36.8 O2 sat 100%•pink•Good air entry, no retractions•Good cardiac tone•Soft abdomen•Full pulses

Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemia, unspecified, resolved

•Aminophylline discontinued

•Piperacillin- Tazobactam


•Episodes of desaturations•Episodes of apnea (5-10 seconds, HR 80’s-90’s, O2 saturation 70%) w/c responds to tactile stimulation

•VS: HR 150, RR 49, T 36.6 O2 sat 95%•pink•Good air entry, shallow subcostal retractions•Good cardiac tone•Soft abdomen•Full pulses

Apnea, Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemia, unspecified, resolved

•Labs: CBC, hgt

•O2 support •Aminophylline resumed•Piperacillin- Tazobactam increased to 120 mg (100 mg/kg/dose)

• CBC, hgt, chest xray

CBC


143 43 14.4 20 47 16 10 7 522 Slight toxic granules

HGT 92


•Episodes of desaturations •Episodes of apnea (10-20 seconds, HR 60’s-70’s, O2 saturation 70%) w/c responds to tactile stimulation

•VS: HR 150, RR 49, T 36.6 O2 sat 95%•Pink, mottled skin•Good air entry, shallow subcostal retractions•Good cardiac tone•Soft abdomen•Full pulses


•Labs: blood culture, urinalysis, Chest xray, Na, K, Bilirubin levels, Hgt, blood gas

•Nasal CPAP intubation

•Aminophylline increased to every 8 hours

(cont.) 15th day of lifeSubjective Objective Assessment Plan

•Episodes of desaturations •Episodes of apnea (10-20 seconds, HR 60’s-70’s, O2 saturation 70%) w/c responds to tactile stimulation

•VS: HR 150, RR 49, T 36.6 O2 sat 95%•Pink, mottled skin•Good air entry, shallow subcostal retractions•Good cardiac tone•Soft abdomen•Full pulses


•Piperacillin- Tazobactam discontinued shifted to Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)

VBG


7.24 55.7 33 24 26 -3.0 Respiratory Acidosis

Chest Xray unchanged bilateral lung opacities consistent with resolving hyaline membrane disease

Blood Culture

Hgb Hct

126 37HGT

Urinalysis

RBC WBC Epithelial Cast Bacteria

2 5 61 0 14

Na K iCal139 4.9 139

Bilirubin Levels


4.54 0.38 4.22 LRZ


•Intubated•FR 8•FiO2 20•RR 20•PIP 10•PEEP 4• iT 0.5•No desaturations

•VS: HR 141, RR 52, T 37 O2 sat 100%•Pink•Good air entry, shallow subcostal retractions•Good cardiac tone•Soft abdomen•Full pulses


•Labs: Blood gas

•Nasal CPAP intubation

•Aminophylline decreased to every 12 hours

•Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)

VBG


7.261 63.4 35.7 28.4 57.9 -0.2 Respiratory Acidosis

Current Diagnosis

Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild

Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified,

Resolved

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NICU AUDIT