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

Past Medical History Feb – 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 G , 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

2 nd Hour of life SubjectiveObjectiveAssessmentPlan 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 pHpCO2PO2HCO3O2BE Compensated Respiratory Acidosis Chest Xray Consider Hyaline Membrane Disease, cannot totally rule out Neonatal Pnemonia Blood Culture No Growth (7 days) CBC HgbHctWBCBandNeuLympMonEosPlt nRBC /100 WBC HGT82

1 st day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, unspecified Labs: Bilirubin Levels, CRP, Chest Xray, Hgt Single Overhead Phototherapy Oxacillin, Cefotaxime, Amikacin

Bilirubin Levels TotalDirectIndirect Chest Xray Consider Hyaline Membrane Disease, with interval improvement in the Lung Status CRP 0.21 mg/dl HGT152 VBG pHpCO2PO2HCO3O2BE Compensated Respiratory Acidosis

2 nd day of life SubjectiveObjectiveAssessmentPlan Intubated FiO2 40% RR 40 PIP 12 PEEP 4 iT 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, Hyperbilirubinemi a, unspecified Labs: VBG, Na, K, Hgt Single Overhead Phototherapy Started feedings TPN started Oxacillin, Cefotaxime, Amikacin

VBG pHpCO2PO2HCO3O2BE Compensated Respiratory Acidosis NaK HGT137

3 rd day of life SubjectiveObjectiveAssessmentPlan Intubated FiO2 40% RR 35 PIP 12 PEEP 4 iT 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 Mild Respiratory Distress Syndrome, Sepsis, unspecified, Hyperbilirubinemi a, unspecified Labs: Hgt (123) Single Overhead Phototherapy Oxacillin, Cefotaxime, Amikacin

4 th day of life SubjectiveObjectiveAssessmentPlan Extubated Shifted to nasal IPPV FiO2 30% PIP 12/4 RR 15 iT 0.4 FR 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, Hyperbilirubinemi a, unspecified Labs: Hgt (119) Single Overhead Phototherapy Epinephrine 0.1 ml 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,Cefota xime, Amikacin

5 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, 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 TotalDirectIndirect LRZ NaK HGT87

7 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, 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 HgbHctWBCBandNeuLympMonEosPlt Slight toxic granules HGT68

12 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, unspecified, resolved Aminophylline discontinued Piperacillin- Tazobactam

14 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, unspecified, resolved Labs: CBC, hgt O2 support Aminophylline resumed Piperacillin- Tazobactam increased to 120 mg (100 mg/kg/dose)

CBC, hgt, chest xray CBC HgbHctWBCBandNeuLympMonEosPlt Slight toxic granules HGT92

15 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, unspecified, resolved Labs: blood culture, urinalysis, Chest xray, Na, K, Bilirubin levels, Hgt, blood gas Nasal CPAP  intubation Aminophylline increased to every 8 hours

(cont.) 15 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, unspecified, resolved Piperacillin- Tazobactam discontinued shifted to Meropenem 24 mg IV every 12 hrs (20 mg/kg/dose)

VBG pHpCO2PO2HCO3O2BE Respiratory Acidosis Chest Xray unchanged bilateral lung opacities consistent with resolving hyaline membrane disease Blood Culture HgbHct HGT Urinalysis RBCWBCEpithelialCastBacteria NaKiCal Bilirubin Levels TotalDirectIndirect LRZ

16 th day of life SubjectiveObjectiveAssessmentPlan 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, Hyperbilirubinemi a, 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 pHpCO2PO2HCO3O2BE Respiratory Acidosis

Current Diagnosis Prematurity, Very Low Birth Weight, Apnea of Prematurity, Sepsis, Mild Respiratory Distress Syndrome, Hyperbilirubinemia, unspecified, Resolved