General Information

NF 2 months/female Filipino Roman Catholic Sapang Palay, Bulacan DOB: July 1, 2014 DOA: September 6, 2014

CHIEF COMPLAINT

Fecaloid discharge

from post-op site

History of Present Illness

Diagnosed case of Gastroschisis Admitted at our NICU from July 2014 to August 20,

2014, discharged apparently well, with weight of 2.2 kg, fed with purchased EBM from milk bank

Seen at the Neonatology OPD 7 days PTA, advised admission due to dehydration; admitted for 1 day at our ER and discharged apparently well

1 day PTA, mother noted fecaloid material coming out from post-operative site

Persistence prompted consult to our ER

History of Present Illness

10 hours prior to

admission

• Fever, Tmax: 38.2 ˚C• Fecaloid material from post-op site•No cough, colds, no vomiting•No bowel movement, last BM was 1 day PTA• Poor suck and activity•No consult done•No meds given

History of Present Illness

two hours PTA

• Post-op wound with surrounding erythema, which continuously draining fecaloid discharge• (+) fever•Poor suck and activityADMISSION

Review of Systems

General: poor weight gain HEENT: No ear discharge, no colds, good suck Cardiac: No cyanosis when feeding GI: (+) changes in the consistency of the stools GU: no decrease in urine output, no changes in the

color of urine Hematologic: No pallor, occasional and minimal

bleeding on the lesions on the inguinal area Musculoskeletal: No muscle weakness, no joint

swelling Neurologic: No seizures

Birth and Maternal history

Born to a 18 y/o G2P2 (2002), nonsmoker, nonalcoholic beverage drinker.

regular PNCU since 2 months AOG at a LHC, attended by a midwife.

with intake of MVS, FeSO4 UTZ at 5 months AOG, (+) protruding

mass over umbilicus No maternal illness noted No Congenital Scan

Birth and Maternal History

Delivered full-term, via NSD at Sapang Palay District Hospital c/o midwife, with good cry and activity

(+) abdominal wall defect with gastric contents protruding, lateral to the umbilicus

Given Erythromycin ointment, OGT inserted, gastric contents wrapped in a gauze soaked in PNSS, advised THOC to PCMC

Admitted at the Neonatal ICU for 1 1/2 months

Family History

29 30

2mos

No history of Hypertension, DM, Bronchial Asthma, Allergy, Malignancy, Seizure disorder

2 y/o

Immunization History

BCG x 1 dose Hep B x 1 dose

Nutritional History

Started on EBM at birth fed through OGT, shifted to formula feeding Bona 1:2 dilution, 4oz q4

No residuals. No swallowing difficulties

Developmental History

Gross motor Poor head control

Fine motor fisting

Language coos

Personal Social No social smile

Personal Social History

Lives in a well lit, well ventilated house with extended family on the paternal side, together with 7 household members

Primary caregiver: Mother Source of water: tap water Garbage collected twice a week House not near factories and highways

Past Medical History

Previously admitted at our NICU: last July 3, 2014 to August 18, 2014 due to Gastroschisis, s/p emergency application of IV bag, s/p abdominal wall closure using MESH 7/25/2014, Sepsis (Candida), resolved; AKI due to Sepsis, resolved; SSI (p. Aeruginosa), resolved

Readmission last August 28, 2014 due to AGE, admitted for 1 day at our ER

Physical Examination on Admission General Survey: awake, not in

respiratory distress Wt: 2.0 kg (z score: <-2 ) VS:

Temp 36.0 CR 122 RR: 41

Physical examination

Skin: no jaundice, no cyanosis HEENT: No skull deformities, (+) sunken

fontanels, anicteric sclerae, (+) pale palpebral conjunctiva, no eye discharge, (-) ear discharge, no alar flaring, moist lips and tongue, no buccal mucosal lesions, no tonsillopharyngeal congestion

Chest: symmetric chest expansion, shallow subcostal and intercostal retractions, clear breath sounds

Physical examination

Heart: adynamic precordium, no heaves, thrills or lifts, normal, regular rhythm, no murmurs

Abdomen: globular abdomen, normoactive bowel sounds, (+) fecaloid material from post-operative site, greenish pasty output approximately 10ml

Extremities: Faint pulses, cold extremities, no cyanosis, no edema, CRT <2 secs

Neurologic exam: intact cranial nerves, spontaneous movement of both extremities, normoreflexive, no nuchal rigidity, no nystagmus

Admitting Diagnosis at the Wards

Gastroschisis, s/p Abdominal Wall Closure using

MESH (7/25/2014), Sepsis,

Healthcare-Acquired Infection

Course in the Wards

Course in the wards 1st HD

S/O P

6:00 AMSeen by Surgery at ER

8:00 AMWeak looking, sunken fontanels, sunken eyeballs(+) fecaloid material over post-op site

Cbc:Hgb: 67Hct: 20WBC: 22Segmenters: 70Lymph: 26Mono: 4Platelets: 218• Wound GS,

CS• Blood CS

Admit to Surgery WardNPOD5LR mild for 6 hoursPLR vol/vol

replacementPRBC (10ml/kg/aliq) x

3Therapeutics• Refer to PIDS for

Meropenem (60)• Insert OGT, cutdown• Refer to Gastro

Service for comanagement

Course in the wards 2nd HD

S/O P

AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fecaloid material approximately 20mlFull and equal pulsesUO 5.1ml/kg/hr

• Wound GS, CS

• Blood CSPost PRBC Cbc:Hgb: 142Hct: 42WBC: 19.6Segmenters: 64Lymph: 33Platelets: 163

NPOD5IMB (Mtn)PLR vol/vol

replacements/p PRBC

(10ml/kg/aliq) x 3Therapeutics• Meropenem (60)• Mupirocin ointment

on affected areas• Updated Gastro

Service, for formal referral

Course in the wards 3rd HD

S/O P

AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fistula output 30mlFull and equal pulsesUO 3.4ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus

• Wound GS, CS

• Blood CS

For Emergency Removal of MESH

Standby 1 u PRBC for OR use

GASTRO: Ideally to start TPN, however without funds hence maintained on D7.5IMB

Course in the wards 4th HD

S/O P

AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupils(+) fecaloid material approximately 30mlFull and equal pulsesFB +309UO 12.2 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus

Awaiting funds for• Wound CS• Blood CSPost PRBC Cbc:Hgb: 119Hct: 35WBC: 12Segmenters: 61Lymph: 28Monocytes: 11Platelets: 140Urine KOHNBS

s/p removal of MESH, post-op Day 1

NPONo funds for TPN;

D10IMB (mtn)PLR vol/vol

replacement• Meropenem (60)• Referred back to

PIDS for possible use of Fluconazole, continue Meropenem

GASTRO: Facilitate TPN, suggest rectal stimulation

Course in the wards 5th HD

S/O P

AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupilsIntact post-op dressing, no fecaloid materialFull and equal pulsesUO 13.4 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus

Awaiting funds for• Wound CS• Blood CS

s/p removal of MESH, post-op Day 2

NPONo funds for TPN;

D12.5IMB (mtn)PLR vol/vol

replacement• Meropenem (60)• Referred back to

PIDS for possible use of Fluconazole, continue Meropenem

GASTRO: Facilitate TPN, rectal stimulation

Course in the wards 6th-7th HDS/O P

AwakeNot in distressFlat fontanelsPink conjunctiva, anicteric sclerae, isocoric pupilsIntact post-op dressing, no fecaloid materialFull and equal pulsesFB -25UO 10.4 ml/kg/hr(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus

Awaiting funds for• Wound CS• Blood CS

Electrolytes:Na 142, K 4.9, Cl 116, Ca 2.33

s/p removal of MESH, post-op Day 2

Start Milk Formula 5cc q6 via OGT

No funds for TPN; D12.5IMB (mtn)

PLR vol/vol replacement

Meropenem Day 6GASTRO: Facilitate TPN, rectal stimulation

Course in the wards 8th HD

S/O P

(+) hypoglycemic episodes, s/p 2 doses of D10W (5) IV bolus(+) septic shock

CBCElectrolytesPTAPTTRandom urine sodium

post-op Day 4O2 at 10LPM

Referred to ICUMeropenem Day 8, with missed dosesReferred back to PIDS for Fluconazole use-Started on Ciprofloxacin, Metronidazole, Amphotericin, Vancomycin

Course in the wards 9th HDS/O P

11:00AmAsleep, but arousable(+) still with episodes of hypothermia and hypoglycemia(+) abdominal distentionHypoactive bowel sounds(+) bleeding on previous extraction site

A: Septic shock, T/C DIC secondary to Sepsis

PT 15.2, 11.2, 56.6, 1.36APTT 43.9, 27.5

PNSS at 20cc/kgFor PRBCFor FFPContinue IV antibioticsCipro d2Metro d2Ampho d2Vanco d2Keep thermoregulated For Serum electrolytes

Course in the wards 10th HDS/O P

10:00pmDrowsy, but arousableCR: 90 RR: 30 O2 sat: 93% Temp 34 36.5C(-)alar flaringShallow subcostal retractions and intercostal retractionsClear breath soundsGlobular abdomen, hypoactive bowel sounds, Soft abdomenFair pulses, cold extremities(+) bleeding on previous IV sitesCRT <2 secsPupils 2-3 EBRTL

A> Sepsis, HCAI

ThermoregulatedHook to cardiac monitorHook to O2 at 10LPMKeep thermoregulatedFor Chest xray to include abdomenFor ABGStill for blood CS, serum elec, PT, PTT

For intubation (Appraised parents)

Course in the wardsS/O P

11:25 pmPupils Sluggishly reactive to light

Pupils anisocoric, Gasping, CR: 80sPoor Pulses, cold ext

BP: 0CR: 30-40, gasping , T:34Cpoor pulsesCRT 3 secondsCold ext

For intubation

Start High Quality CPRPNSS (20cc/kg) BolusGive Epi (1:10,000) 0.19 cc IVICU updated

Course in the wardsS/O P

11:25 pmBP: 0 CR: 0, RR: 0 , T:35CRT: 3-4 secondsPoor pulses, cold ext

9/17/201412:00 AMDilated pupilsCR: 0 RR: 0 No pulses

Continue High quality CPRGive another PNSS (20cc/kg) BolusGive Epi (1:10,000) 0.19 cc IV x 6 doses every 2 minutes

Pronounced deadRender post mortem careAutopsy offered but refused

Final Diagnosis

Septic Shock Disseminated Intravascular Coagulation Healthcare Acquired Infection Failure to thrive