Admission to SCN – A Case Admission to SCN – A Case Study (Baby B)Study (Baby B)

By: Nicole StevensBy: Nicole Stevens

Goals for todayGoals for todayProvide background pathophysiology on Provide background pathophysiology on the main issues that preterm babies face the main issues that preterm babies face during a stay in SCNduring a stay in SCNDiscuss the implications for families who Discuss the implications for families who face a baby having a prolonged stay in face a baby having a prolonged stay in SCNSCNAlso look at the types of babies readmitted Also look at the types of babies readmitted from homefrom homeHear from Judy Russell (Clinical Hear from Judy Russell (Clinical consultant/lactation) on the feeding issues consultant/lactation) on the feeding issues for mothers with preterm babies and those for mothers with preterm babies and those readmitted from homereadmitted from home

Maternal BackgroundMaternal BackgroundEbony: G2P1 (1 year old boy, alive and Ebony: G2P1 (1 year old boy, alive and well), 21 yrs old; Opos, antibody –ve, well), 21 yrs old; Opos, antibody –ve, rubella low immunity, serology neg.rubella low immunity, serology neg.Hx: hyperthyroidism/Graves disease (on Hx: hyperthyroidism/Graves disease (on carbimazole), GDM (diet controlled), carbimazole), GDM (diet controlled), depression, low BMI (17), smokerdepression, low BMI (17), smokerRoutine care through pregnancy, mother Routine care through pregnancy, mother reported nil issues.reported nil issues.Presented in preterm labour at Presented in preterm labour at 32.2wks32.2wks to to BHSBHSProceeded to Em LUSCS due to breech Proceeded to Em LUSCS due to breech presentationpresentation

Birth/ResuscitationBirth/ResuscitationDifficult footling breech extraction (LUSCS)Difficult footling breech extraction (LUSCS)Present for resus: paed reg, SCN nurse, Present for resus: paed reg, SCN nurse, midwife and paed residentmidwife and paed residentROM/clear liquor at time of LUSCSROM/clear liquor at time of LUSCSApgars: 4@1, 8@5, 9@10Apgars: 4@1, 8@5, 9@10Respirations est. by 5 mins, required IPPV Respirations est. by 5 mins, required IPPV in air then oxygen, then ongoing CPAP in in air then oxygen, then ongoing CPAP in oxygen (30%) for transport.oxygen (30%) for transport.

Admission to SCNAdmission to SCNBaby B admitted to SCN from theatreBaby B admitted to SCN from theatreBW: 1860gBW: 1860gCPAP ongoing via transport prongsCPAP ongoing via transport prongsIV cannula inserted, blds taken (culture, IV cannula inserted, blds taken (culture, FBE, CRP, TBG and venous gas)FBE, CRP, TBG and venous gas)Examined well, not dysmorphicExamined well, not dysmorphicUnknown cause for preterm labour, Unknown cause for preterm labour, managed for potential sepsis.managed for potential sepsis.Moved to an incubator and managed on Moved to an incubator and managed on CPAP 5 (cm/H2O)/bubble CPAP initially, CPAP 5 (cm/H2O)/bubble CPAP initially, with minimal oxgyen requirementwith minimal oxgyen requirement

Potential SepsisPotential SepsisIn the cases of preterm labour, it is usual practice to err on In the cases of preterm labour, it is usual practice to err on the side of caution and assume it may be an infection that the side of caution and assume it may be an infection that has caused the preterm labour, so the preterm newborn is has caused the preterm labour, so the preterm newborn is ‘covered’ with antibiotics until considered safe to cease (min. ‘covered’ with antibiotics until considered safe to cease (min. 48 hrs)48 hrs)Bloods taken for FBE, CRP and culture as IV cannula insertedBloods taken for FBE, CRP and culture as IV cannula insertedCommenced on Benzylpenicillin 12/24 and Gentamycin 36/24Commenced on Benzylpenicillin 12/24 and Gentamycin 36/24CRP results: 26/8 1, 29/8 <1, 3/9 <1CRP results: 26/8 1, 29/8 <1, 3/9 <1No growth noted on cultures after 5 daysNo growth noted on cultures after 5 daysFBE results NAD on 3 dates.FBE results NAD on 3 dates.Received 2 days of IV antibiotics and then ceaed. Nil further Received 2 days of IV antibiotics and then ceaed. Nil further episodes of suspected sepsis to date.episodes of suspected sepsis to date.

Respiratory Distress SyndromeRespiratory Distress SyndromeMain risk factor: prematurity, SPTL (no time for Main risk factor: prematurity, SPTL (no time for steroids)steroids)Early evidence of increased WOB, tachypnoea Early evidence of increased WOB, tachypnoea and oxygen requirementand oxygen requirement

(time would prove if it is a differential diagnosis (time would prove if it is a differential diagnosis of TTN)of TTN)

Initial cap gas result (at 1hr): pH: 7.086, PCO2: Initial cap gas result (at 1hr): pH: 7.086, PCO2: 76.8, Lact: 1.82, HCO3: 25, BE: -776.8, Lact: 1.82, HCO3: 25, BE: -7

4.5hrs later: pH: 7.24, PCO2: 55.2, HCO3: 23.7, 4.5hrs later: pH: 7.24, PCO2: 55.2, HCO3: 23.7, BE: -4BE: -4

24hrs later: pH: 7.285, PCO2: 44.2, HCO3: 21.0, 24hrs later: pH: 7.285, PCO2: 44.2, HCO3: 21.0, BE: -6BE: -6

Acid Base BalanceAcid Base BalanceBaby B presents with a respiratory acidosis, low Baby B presents with a respiratory acidosis, low base excess is ignored because of the base excess is ignored because of the significantly elevated PCO2 (makes it a likely significantly elevated PCO2 (makes it a likely error), use HCO3 to interpret metabolic error), use HCO3 to interpret metabolic component.component.Normal Values:Normal Values:

Respiratory acidosis (pCO2 >= 50 mmHg, pH Respiratory acidosis (pCO2 >= 50 mmHg, pH < 7.25)< 7.25)

Respiratory alkalosis (pCO2 < 35 mmHg, pH > 7.40)Respiratory alkalosis (pCO2 < 35 mmHg, pH > 7.40)Metabolic acidosis (HCO3< 18 mmol/L or B.E. < Metabolic acidosis (HCO3< 18 mmol/L or B.E. <

minus 4.0 mEq/L, pH < 7.25) minus 4.0 mEq/L, pH < 7.25) Metabolic alkalosis (HCO3 > 25 mmol/L or B.E. > Metabolic alkalosis (HCO3 > 25 mmol/L or B.E. >

plus 4.0 mEq/L, pH > 7.40)plus 4.0 mEq/L, pH > 7.40)

RDSRDSInitially managed on CPAP of 5 cm/H20Initially managed on CPAP of 5 cm/H20Increased to 6cm at approx 7hrs of age Increased to 6cm at approx 7hrs of age due to increase in FiO2 (up to 30%due to increase in FiO2 (up to 30%CXR taken – confirming RDS, nil other CXR taken – confirming RDS, nil other issues, NGT in place, no pneumothoraxissues, NGT in place, no pneumothoraxReduced back to 5cm next day (in air)Reduced back to 5cm next day (in air)Remained in air and ceased CPAP next Remained in air and ceased CPAP next morning (just over 41hrs old)morning (just over 41hrs old)Remained off CPAPRemained off CPAP

ApnoeaApnoeaBaby received 41+hrs of CPAP supportBaby received 41+hrs of CPAP support12 hrs after cessation of CPAP, had 2 episodes of 12 hrs after cessation of CPAP, had 2 episodes of apnoea, bradycardia and desaturation requiring apnoea, bradycardia and desaturation requiring stimulationstimulationIn between episodes had normal observations and In between episodes had normal observations and respiratory effortrespiratory effortDecision made to caffeine load (20mg/kg, IV)Decision made to caffeine load (20mg/kg, IV)Ongoing daily dose at 5mg/kg (IV/oral) also orderedOngoing daily dose at 5mg/kg (IV/oral) also orderedDose increased to 10mg/kg 2 days later, due to Dose increased to 10mg/kg 2 days later, due to ongoing issues of apnoeaongoing issues of apnoeaAt 34wks CA, reduced back to 5mg/kgAt 34wks CA, reduced back to 5mg/kgLikely to be ceased at approx 35 – 36wks CALikely to be ceased at approx 35 – 36wks CA

HyperbilirubinaemiaHyperbilirubinaemiaNoted to look jaundice on day 2Noted to look jaundice on day 2

SBR results:SBR results:27/8 at 1215 160/2 (total/direct)27/8 at 1215 160/2 (total/direct)Commenced phototherapyCommenced phototherapy28/8 at 1500 87/3 28/8 at 1500 87/3 Ceased phototherapyCeased phototherapy29/8 at 1140 112/2 29/8 at 1140 112/2 6/9 at 1123 120/56/9 at 1123 120/5Nil further monitoring of jaundice levelsNil further monitoring of jaundice levels

FeedingFeedingInitially kept NBM, on CPAP, intermittent Initially kept NBM, on CPAP, intermittent tachypnoea, so risk of aspiration. Hydration tachypnoea, so risk of aspiration. Hydration managed with 10% dextrose infusion, initial TBG managed with 10% dextrose infusion, initial TBG of 2.0mmol/L (at point of IVC insertion) – infusion of 2.0mmol/L (at point of IVC insertion) – infusion commenced and resolved, nil further commenced and resolved, nil further hypoglycaemia issueshypoglycaemia issuesCommenced on small amounts of EBM as Commenced on small amounts of EBM as available and for comfort from 12 hrs of ageavailable and for comfort from 12 hrs of ageBy 36hrs of age regular 3 x 8 feeds commenced By 36hrs of age regular 3 x 8 feeds commenced via the NGT and dripped weaned accordinglyvia the NGT and dripped weaned accordinglyTFI progressed through usual rates of increase for TFI progressed through usual rates of increase for a preterm baby.a preterm baby.

FeedingFeedingOngoing issues with feeding (intolerance)Ongoing issues with feeding (intolerance)Changes implemented in response:Changes implemented in response:

• Reduced TFI Reduced TFI • Increased frequency from 3/24 to 2/24.Increased frequency from 3/24 to 2/24.• Fortifier had been commenced when tolerating Fortifier had been commenced when tolerating

appropriate of feeds, but vomitting exaccerbated appropriate of feeds, but vomitting exaccerbated by this, so ceased againby this, so ceased again

• Maintained on 2/24 feeds, reduced TFI, and no Maintained on 2/24 feeds, reduced TFI, and no fortifier until tolerating; now in the process of fortifier until tolerating; now in the process of slowly grading up TFI and extending out to 3/24 slowly grading up TFI and extending out to 3/24 again (currently 34.4wks)again (currently 34.4wks)

More in depth baby feeding, lactation advice from More in depth baby feeding, lactation advice from Judy Russell!Judy Russell!

Summary of IssuesSummary of IssuesPreterm labour & birth/suspected Preterm labour & birth/suspected sepsissepsisRespiratory distress (TTN or RDS – Respiratory distress (TTN or RDS – time will tell, but likely RDS due to time will tell, but likely RDS due to gestation)gestation)HypoglycaemiaHypoglycaemiaApnoea of prematurityApnoea of prematurityJaundiceJaundiceFeed intoleranceFeed intolerance