A 1 day old baby with neonatal sepsis .ppt

A 1 day old baby with neonatal sepsis

1. WELCOME
To
Clinical Meeting
Dr. Tahina Akhtar
Resident, Year 1
Dept. of Neonatology, BSMMU

2. Particulars Of The Patient
•Name : B/O Nasrin Sultan
•Inborn
•Age : 42 hours
•Date of Birth : 01/04/2018 11:30 pm
•Sex : Male
•Address : Daudkandi,Cumilla
•Date of Admission : 03/04/2018
•Date of examination : 03/04/2018
•Informant : Mother

3. Chief Complaints
•Yellowish colouration of skin .
• Relluctant to feed and less activity and less
activity.

4. History Of Present Illness
Mother Nasrin, 36 years old, para 3+0 having blood
group o+ve, was on regular antenatal check-up and
duly immunized against Tetanus .She is a known
case of bronchial asthma and had H/O taking
salbutamol inhaler , tab. montelukast. She had no
H/O GDM, PIH, fever with rash, hypothyroidism or
any other chronic illness .Her pregnancy was
uneventful upto 39 weeks of gestation .Then she
developed labour pain .

5. History Of Present Illness
A male baby weighing 3000 grams delivered by NVD.
Baby cried immediately after birth and Apgar score
was 8 & 9 in 1
st
and 5th minutes respectively .At 36
hours of PNA baby developed yellowish
discolouration of skin and sclera .TCB was done and
level was 256umol/L,SL was 162 umol/L and TSB was
sent.TSB was 14mmol/L that corresponds to
phototherapy level.

6. Mother also complained that baby had decreased
urinary output and excessive crying during micturation
for last 24 hours.For these reason baby was shifted to
NICU in doctor’s lap with proper wrapping and
transportation time was around 8 minutes.
History Of Present Illness

7. Birth history
•Antenatal History Immunized with TT, was on
regular antenatal check-up. She had no H/O fever with
rash, DM, PIH, hypothyroidism or any other
illness.Mother is known case of Bronchial asthma.
•Natal History : Baby was delivered by NVD. Baby cried
immediately after birth.
•Post natal history: Baby developed jaundice at PNA
36 hours and decreased urinary output with
excessive crying during micturation.

8. Family history
He is the 3
rd
issue of a nonconsanguineous marriage.
His previous two sibs had no this type of illness.

9. Socioeconomic history
Belongs to lower socioeconomic condition. Father is a
businessman and mother is a worker of daudkandi
health complex.

10. General Examination
On arrival

Baby is leathergic and icteric upto abdomen
HR- 136 bpm
SPO-97% without supplemental O2
 RR- 42/min
 Temperature- 98.4 ⁰ F
 CRT- 2 sec
 CBG- 4.3 mmol/L

11. .
Skin survey : Normal
Genitalia: Male pattern.
Back and spine: Normal.
No apparent congenital anomaly.
General Examination

12. .
•Weight: 3000 grams (between 25
th
to 50
th

centile)
•Length: 49 cm (Between 25
th
to 50
th
centile)
•OFC: 33 cm (Between 25
th
to 50
th
centile)
•On admission weight:2650gram(110% loss)
Anthropometry

13. Weight chart

14. Length chart

15. OFC chart

16. .
 Baby was conscious
 Primitive reflexes-
 Moro, rooting, sucking- good
 Palmar and planter grasp-present
 Cranial nerves- Intact
 Pupil- constricted, reacting to light
 Tone- Normal
 Jerks- Normal
Nervous system

17.  Chest movement symmetrical
 Bilateral good air entry
 No added sound
Respiratory System

18.  No visible pulsation
 Apex beat- Left 4th intercostal space, medial to
midclavicular line
 1
st
and 2
nd
heart sound normal
 No murmur
Cardiovascular system

19.  Not distended.
 Umbilicus : Healthy
 Liver- not palpable
 Spleen: not palpable
 Bowel sound : present.
 Genitalia: male pattern.
 Anus: Normal in position and patent.



Abdomen and Genitalia

21. Salient Feature
S/O of Nasrin, 3rd issue of non consanguineous parents,
inborn, admitted at 42 hours of age with the complaints
of yellowish discolouration of skin,reluctant to feed and
poor feeding .
Mother Nasrin, 36 years old, Para 3+0, having blood
group O+ve , diagnosed case of Bronchial Asthma which
was well controlled. She underwent NVD at 38 weeks of
gestation and delivered a male babyweighing 3000gram

22. and the baby cried immediately after birth. Apgar score was
8 & 9 in 1
st
and 5
th
minutes respectively. He developed
jaundice which corresponds to photo level and baby was
reluctant to feed and poor active.baby also had decreased
U/O(1 times in last 24 hrs).So soon after that baby was
transferred to NICU.
On arrival, patient was leathergic,poor active HR-136bpm,
SPO2-97%, RR- 42/min, CRT- 2 sec, CBG- 4.3
mmol/min,weight loss 110%.
Salient Feature

23. Anthropometrically baby’s was 25
th
to 50
th
centile. On
Genito-Urinary system examination . Other systemic
examination revealed no abnormality.
Salient Feature

24. Provisional Diagnosis

25. Provisional Diagnosis
Term (39 weeks) AGA (3000 grams),with EONS
with Neonatal Jaundice .

26. Points In Favour of Inborn Error of Metabolism
•Consanguinity
•Previous two siblings with similar presentation
•Convulsion

27. Treatment on Admission
•Thermal care
•Cup spoon feeding
• Inf. 10% DBS
• Inj. Ampicillin
•Inj. Gentamicin
•Single surface phototherapy

28. Investigation
•Septic screening
•CBC with PBF
•S. Electrolytes
•S. Calcium
•S. Magnesium
•S. Creatinine
•Blood grouping
•Coomb’s test
•Blood C/S

29. F/U on 03/04/2018, PNA- 43 hours
Subjective Objective Assesment/planintervention
Tonic seizure of all
four limb.
Inj Ampicillin
Inj Gentamicin
Icteric upto
abdomen
Reflex activity-poor
SPO2- 98% with O2
2L/min
CRT 2sec
RR- 36/min
HR-132bpm
Temp-100.8 F
Lung- good air entry
Heart- S1+S2+0
CBG – 4.2 mmol/L

Meningitis/any
metabolic
disorder
Inj phenobarbitone
collect septic work
up,blood
c/s,s.electrolyte,s.creatini
ne.

30. InvestigationFindings on 03/04/2018
CBC Hb : 19.9 g/dl
TLC : 25,000/cumm
DLC : N-70%, L-24%
PLT : 70,000/cumm
PBF thrombocytopenia
IT ratio 0.07
CRP 16.43mg/L
Blood C/S No growth
S.Electrolytes Na- 154mmol/L Cl- 117 mmol/L
K- 5.1 mmol/L TCO2- 18.5 mmol/L
S.Calcium
S.Magnesium
7.3 mg/dl
2.3 mg/dl

31. Investigation
InvestigationFindings on 04/04/2018
s.electrolyte Na-156, K-4.9
Cl-117, TCO2-164
S.Creatinine 1.91mg/dl
USG of W/A Echogenic renal papilla bilaterally in concern with
papillary necrosis. Echogenic debri in Urinary
bladdar

32. F/U on 05/04/2018, PNA- 82 hrs
Subjective Objective Assesment/planintervention
No urine output
for last 12 hrs
Hypernatraemia ,
raised creatinine
Inj Ampicillin
Inj Gentamicin
with adjusted renal
dose.
Inj ca gluconate
Icteric upto thgh
Reflex activity-good
RR-36/min
SPO2- 97% with O2
0.5 L/min
CRT -2 sec
BP-102/27(51) [ S-61-
73,D-38-48,M-46-56]
HR-130bpm
Temp-98 F
Lung- good air entry
Heart- S1+S2+0
CBG –5.1mmol/L
U/O- 50 ml /day(0.8)
ml/kg/hr
wt gain-0.41
gm/kg/day
Deteriorating
Plan:
nephrologist
consultation
Fluid adjusted(140ml/kg)
10% libott s junior(100ml)
10% DBS(200ml)
Feed(120ml)
Inj Ampicillin-12 hrly
Inj Gentamycin-48 hrly
Inj ca gluconate upto s.ca
level 8 mg/dl

33. InvestigationFindings on 06/04/2018
S.Electrolyte Na-139mmol/L
K-4.3mmol/L
Cl-108 mmol/L
Tco2-16.8mmol/L
S.creatinine 1.65mg/dl
S.calcium 6.8 mg/dl

34. F/U on 07/04/2018, PNA- Day 7
Subjective Objective Assesment/planintervention
Hypernatraemia
corrected
S.Creatinine
decreasing patern
Hypocalcaemia
Inj Ampicillin
Inj Gentamicin
with adjusted renal
dose.
Inj ca gluconate
Pink with O2
0.5L/min
Reflex activity-good
RR-34/min
SPO2- 97% with O2
0.5 L/min
CRT -2 sec
BP-167/40(87) [ S-64-
76,D-20-50,M-48-58]
HR-119bpm
Temp-98 F
Lung- good air entry
Heart- S1+S2+systolic
murmur.
CBG –4.7mmol/L
U/O- ml/kg/hr
wt gain-14
gm/kg/day
Improving
Plan:
nephrologist
consultation
Advice to stop
Libott junior
Continue Ca
gluconate.
Increase feed.
Stop O2
inhalation.
Plan for Echo.
Fluid(150ml/kg)
10% DBS(234ml)
Feed(216ml)-cup
spoon/breast feed trial
Inj Ampicillin-12 hrly
Inj Gentamycin-48 hrly
Inj ca gluconate upto s.ca
level 8 mg/dl

35. S. Creatinine F/U chart
•03.04.18- 1.55 mg/dl
•04.04.18-1.91 mg/dl----Nephrologist consultation
done,fluid adjusted,antibiotic dose adjusted, advice
for regular monitoring of U/O, Inv. S.Electrolyte,
S.Creatinine, S.Calcium daily.
•06.04.18-1.65 mg/dl
•07.04.18-0.98 mg/dl
•08.04.18- 0.55 mg/dl
•09.04.18- mg/dl
•10.04.18-mg/dl
•11.04.18- mg/dl
•12.04.18- mg/dl

37. Final Diagnosis
Term (39 weeks) Appropriate for gestational age
(3000 gram) with Early Onset Neonatal Sepsis with
Neonatal Jaundice (Resolved) with Hypernatraemia
(corrected)with Hypocalcaemia with Acute Kidney
Injury (Papillary Necrosis)