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Background

Ex-premature baby boy at 36 weeks 6 days


APGAR 9/10/10, G6PD : Normal
Mother: 34 years old, Para 2
ANC: GDM on diet control
Blood group: O positive, infective screening: non reactive
History of admission to NICU 30/6/16-7/7/16 for pathological jaundice
Diagnosis at discharge: 1) Resolved sepsis with coagulopthy
-completed IV C-Penicillin and IV Gentamicin 1/52
-Blood C&S (1/7/16): No growth 5 days
2) Late prematurity at 36 weeks 6 days
3) Left undescended testis with ? hypospadia, next TCA Paeds
Surgical 6/2/17

CURRENT DIAGNOSIS
1) Prematurity at 36 weeks
2) Severe bronchopneumonia with lung collapse
3) New onset of sepsis
4) PDA in failure
5) Hypospadia with left undescended testis

PRESENTED WITH
1) Cough x 2/7
-Chesty in nature, worsening, no post tussive vomiting
2) Fever x 2/7
3) Rapid breathing x 1/7, associated with chest recessions

At ETD,
Child tacchypneic, RR 70, SPO2 under room air 88%, with lungs having generalised crepitations with
rhonchi. Given neb salbutamol and was put on FM 5L/min. Reassessment again noted child tacchypneic
with deep recessions, RR 78-80, cyanosed, CRT 3 seconds. Given bolus 10cc/kg and intubated with ETT
size 4mm. Post intubation, another bolus 10cc/kg. Child was admitted to PICU.
PROGRESS IN PICU
05/10/16 Child admitted to PICU and treated as severe bronchopeumonia
Child intubated sedated
Started IV C-Penicillin
Noted systolic murmur with hepatomegally
Bedside ECHO: Good cardiac contractility and normal chambers
Bedside USG Cranium: Bilaterally no IVH seen
06/10/16 Started RTF 15cc/3hourly. Total fluid 60 cc/kg/day
Ejection systolic murmur with hepatomegaly 3cm
Bedside ECHO: All chambers dilated, ? VSD
Formal ECHO done:
Normal chamber sizes
Mild AR with trivial PR
Mild pulmonary hypertension with PAP: 35/20 mmHg
PDA flow noted with PGmax: 49.0 mmHg
No ASD/VSD/PFO/TGA seen
No coarctation of aorta seen
Treated as PDA in failure. Started IV Frusemide 1mg/kg QID
By pm feeding (RTF) increased to 25cc/3 hourly
08/10/16 Changed to PO Frusemide 1mg/kg TDS.
RTF increased to 40cc/3 hourly (100 cc/kg/day)
Tolerated feeding well
Sedation changed to oral sedation
10/10/16 Intubated for 4/7. Extubated to BCPAP FiO2 31%. No desaturation.
Started PO Captopril 0.1 mg/kg BD
Bedside USG: No effusion, one white line seen around left lung (? collapse)
Repeated CXR today revealed whited out appearanceof left lung field
Chaged to Duopap FiO2 40%
11/10/16 Treated as new onset of sepsis due to child inactive, BP low, hypothermia, lung reduced air
entry over left side with CXR showing left lung collapse
Antibiotic escalated to IV Cefuroxime
Started IV Adrenaline 0.2mcg/kg/min (BP 71/32 MAP 41)
PO Captopril witheld
During pm round noted child tacchypneic with recession. Repeated CXR
was worsening.
Child intubated again
12/10/16 Inotropes slowly tapered down. Feeding tolerated, DXT stable. No fever, no desaturation.
13/10/16 Inotropes weaned off. Ventilated on low setting, no desaturation
14/10/16 Child self extubated. Able to wean off to BCPAP FiO2 40%
Started PO Spironolactone 3.125mg BD
PO NaCl 3% increased to 2cc per feed
15/10/16- No desaturation on BCPAP FiO2 40%
17/10/16 Still tacchypneic with recessions
18/10/16 Weaned down to NPO2 1L/min
No desaturation, DXT stable, tolerated RTF 40cc/3 hourly (100 cc/kg/day)
Afebrile, IV Cefuroxime completed
Trasferred out to Child Medical Ward
Investigation results
Date 5/10/16 6/10/16 6/10/16 7/10/16 8/10/16 8/10/1 9/10/16 10/10/16 11/10/16 13/10/16
4pm 12am 12pm 6am 6
6pm
WBC 13.5 23.1 21.7 18.1
Hb 11.4 10.4 10.5 11.6
Hct 35.5 32.6 31.2 35.0
Plt 361 392 423 338

Na 140 141 143 137 140 138 134 138 134 131
K 4.1 3.2 3.39 4.41 2.77 3.65 4.97 3.18 4.1 2.7
Urea 1.8 1.3 1.0 2.3 2.5 3.1 2.5 3.2 3.5 6.6
Creat 22 18 14 32 34 32 23 37 22 43

Ca 1.77 2.09 1.95 1.99 1.87 2.3 1.8


Mg 0.713 0.713 0.724 0.8
PO4 1.29 0.90 1.02

TB
DB
ALT
ALP
Prot
Alb 45.8 46.6 41.5 42.5 36.9 44.3
Glob
AST

CK 541
CKM 43
B

pH 7.015
pCO2 78
pO2 61.2
cHCO3 19.5
BE -11.8

CRP 12.67
Date
14/10/1 15/10/1 17/10/1
6 6 6
WBC
Hb
Hct
Plt

Na 134 140 135


K 5.45 4.5 3.7
Urea 3.9 4.9 5.5
Creat 40 102 40

Ca 2.75
Mg 0.941
PO4 0.71

TB
DB
ALT
ALP
Prot
Alb
Glob
AST

pH
pCO2
pO2
cHCO3
BE

Blood C&S (06/10/16) and (11/10/16): NOG 5 days


Tracheal aspirate C&S (6/10/16) and (11/10/16): NOG 5 days
CRP (6/10/16): 12.67 (13/10/16): PENDING
NPA for RSV (6/10/16): Pending

TFT:
TSH (10/10/16): 0.580
Free T4 (10/10/16): 15.08

ECHO (6/10/16):
Situs solitus, levocardia
Normal chamber sizes
Mild AR with trivial PR
Mild pulmonary hypertension with PAP: 35/20 mmHg
PDA flow noted with PGmax: 49.0 mmHg
No ASD/VSD/PFO/TGA seen
No coarctation of aorta seen

CURRENT DIAGNOSIS
1) Late prematurity at 36 weeks 6 days
2) Severe bronchopneumonia with lung collapse
Completed IV C-Penicillin x 6/7, antibiotics escalated due to new onset of sepsis
Blood C&S (06/10/16): NOG 5 days
Tracheal aspirate C&S (6/10/16):NOG 5 days
NPA for RSV (6/10/16): Pending
Intubated for 4/7 (5/10/16-10/10/16). Extubated to BCPAP FiO2 31% for 1/7.

3) New onset of sepsis


Child was inactive, BP low, hypothermia, lung reduced air entry over left side with CXR showing
left lung collapse
Intubated again for another 4/7 (11/10/16-14/10/16), then on BCPAP FiO2 40% for 4/7, then now
on NPO2 1L/min
Was on single inotrope x 3/7 (11/10/16-13/10/16)
Completed IV Cefuroxime x 1/52
Blood C&S (06/10/16): NOG 5 days
Tracheal aspirate C&S (6/10/16):NOG 5 days
Repeated CRP on 13/10/16 pending

4) PDA in failure

5) Hypospadia with left undescended testis


Next TCA under visiting Paeds Surgical Team on 6/2/17