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

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

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

Problem List:

• Respiratory Distress Syndrome• Infection• Apnea of Prematurity• Hyperbilirubinemia of Prematurity

Prob 1: Respiratory Distress Syndrome2nd Hour of life

Subjective 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

Problem 2: Hyperbilirubinemia1st day of life

Subjective 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

pH pCO2 PO2 HCO3 O2 BE

7.354 59.8 28.4 33.2 50.3 6.6 Compensated Respiratory Acidosis

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

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

•Labs: Hgt (119)

•Single Overhead Phototherapy

•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

5th day of lifeSubjective Objective Assessment Plan

•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

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

•Labs: Hgt, Bilirubin level, Na, K

•Single Overhead Phototherapy

•Shifted to nasal cannula at 0.5 lpm, then discontinued

•Oxacillin, Cefotaxime, Amikacin

Bilirubin Levels

Total Direct Indirect

8.06 0.45 7.75 LRZ

Na K

132 6.3

HGT 87

Prob 3: Infection and Apnea 7th day of life

Subjective Objective Assessment Plan

•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

Hgb Hct WBC Band Neu Lymp Mon Eos Plt

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

HGT 68

14th day of lifeSubjective Objective Assessment Plan

•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

Hgb Hct WBC Band Neu Lymp Mon Eos Plt

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

HGT 92

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

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

•Labs: blood culture, urinalysis, Chest xray, Na, K, Bilirubin levels, Hgt, blood gas•Nasal CPAP intubation •Aminophylline increased to every 8 hours•Pip-Taz discontinued shifted to Meropenem 24 mg IV every 12 hrs (20 mkdose)

VBG

pH pCO2 PO2 HCO3 O2 BE

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

No growth for 24 hrs

Hgb Hct

126 37HGT 92

Urinalysis

RBC WBC Epithelial Cast Bacteria

2 5 61 0 14

Na K iCal139 4.9 139

Bilirubin Levels

Total Direct Indirect

4.54 0.38 4.22 LRZ

16th day of lifeSubjective Objective Assessment Plan

•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

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

•Labs: Blood gas

•Nasal CPAP intubation

•Aminophylline decreased to every 12 hours

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

VBG

pH pCO2 PO2 HCO3 O2 BE

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