Unit 2.1 Neo/pediatric
case studies
Elizabeth Kelley Buzbee AAS, RRTNPS, RCP
Case study

You are called to L & D for a stat C-section
for “late decells.” What is the significance
of this?

The fetal heart rate is decreasing to
bradycardia and not coming back up to
baseline.

What else do you need to know?
answer
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1.
2.
3.
4.
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gestation of baby
mother’s prior birth history
history of this pregnancy
history of this labor
L/S ratio or phospha-tidyl-gycerol levels
Shake test of aminiotic fluid and ethonol


This is 28 weeks gestation. Mom is 25
year old, G2 P2. The labor was
complicated by PROM.
You are concerned because:
answer
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The baby will be premature & at risk for
IRDS type I
The baby is at risk for infection due to the
PROM

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The baby is born. At 1 minute of life, you
see that the HR is 88 bpm, the baby is
apnic, blue and flaccid. He is unresponsive
to tactile stimulation
You respond by:
answer

Mask bag with 100% 02 at a respiratory
rate of 40-60 bpm

What is the APGAR at 1 minute?
Answer:

1 at 1 minute

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At 3 minutes of life with bagging, the baby
starts to pink up, but fails to attempt to
breath. At Fi02 100% by mask bagging,
the Sp02 rises from 73% to 92%
You recommend what?
answer
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Intubate and ventilate the infant
Instillation of artificial surfactant to reduce
the severity of his IRDS type I

Baby is AGA 26 week preemie by exam.
He is intubated with an # 2.5
endotracheal tube and it is taped at the 10
how do you assess this patient now?
answer
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Listen to bilateral breath sound: they are
equal in the right and left at the axillary
but you hear crackles in the upper lobes,
and diminished breath sounds in the basal
areas.
Repeat APGARs in 5 minutes


You are bagging at a PIP of 13 cmH20,
and an Fi02 100% and rate of 45 bpm.
The Sp02 is 93%.
What do you suggest?
answer

Get an arterial blood gas:

The pH is 7.34 the PC02 is 35 and the Pa02 is
65 torr.
Looking at these gases, what do you want
to do?
answer

Get a pressure ventilator set up on the following
settings:
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IMV 45
PIP 13
PEEP 5
Fi02 100%
Ti .30 to .5 seconds [closer to .3 if VSBW infant]
Flow rate 8- 10 lpm
And repeat the gas on these settings


That baby is put onto these settings and
you see good chest movement and you
see the Sp02 on the right hand is 95%
What do you want to do now?
Answer

Get x-ray:

you see low volume lung with diffuse alveolar
infiltrates and air bronchogram

An umbilical artery catheter is placed and in one
hour, you get an ABG on the current settings.

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pH 7.33
PaC02 45
Pa02 48 torr
Sa02 88% [Sp02 is 88%]
What has happened & what do you suggest?
answer
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Increase the Vt by increasing the PIP from
13 to 14.
Increase the PEEP from 5 to 6
Repeat ABG

What is this baby’s most likely diagnosis?
answer

HMD [IRDS type I] but we cannot r/o
intrauterine pneumonia.
Case study # 2

You are called to L & D for a SGA baby who is 32
weeks by date. Mom is G6 P3 A3 and she is 38
years old. She has gestational diabetes
The baby is delivered 5 hours after labor started
and membranes broke.
It is SVVD

What do you expect?
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
answer
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Mom has a bad track record of infant
deaths.
Baby is premature
Baby is not at risk for infection
Even if baby wasn’t premature, he could
have immature lungs

What is a problem with sucessful diagnosis
of IRDS I with a infant of a diabetic mom?
answer
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The L/S ratio may not be accurate,
You need to look at the phospha-tidylgycerol for lung maturity in infant of
diabetic mom

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At birth, baby is flaccid, apnic with heart
rate 95 bpm, blue centrally and
peripherally.
What is the APGAR?
What is your intervention?
answer
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APGAR at 1 minute is 1.
Start bagging with 100% at a rate of 4060 bpm.
Look at Sp02
Listen to breath sounds with bagging
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In 3 minutes, baby is intubated and
bagged with 100% Fi02.
Bilateral breath sounds: equal and
bilateral. Diminished basal breath sounds,
crackles in upper lobes.
Sp02 is 88%
What do you want to do?
answer
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Get an ABG
Note the PIP you are bagging with
Place patient on PEEP
Repeat Sp02 in a few minutes

If you did an L/ S ratio on this kid what
results would you expect?

1. Infant who have L/S ratio of more than
2:1 have mature lungs from the
standpoint of pulmonary surfactant so we
expect this one’s L/S ratio to be less than
2:1
Case study # 3
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Mom is 45 year old WF G3 P3. gestation is 38
weeks.
Stat C-section for late decells
Membranes ruptured at 1300 and the baby
wasn’t delivered till 1500 the next day.
Mom is febrile with respiratory infection
What are the maternal risks, what are we
worried about ?
answer
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38 weeker infant is low risk for IRDS
Febrile and PROM puts baby at risk for
intrauterine pneumonia and sepsis.
Late decells puts baby at risk for fetal
distress.
What do you want to monitor?
answer
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APGAR’s and Silverman’s
Tracheal aspirate for culture and sensitivity
Spinal tap and blood cultures for sepsis
Breath sounds and pulse oximetry
Case study # 4
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Baby is a 39 weeker who is delivered by
elective C-section on Feb 14 because the
parents want a ‘valentine baby’
How do you assess this infant?
answer
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Get APGAR at 1 minute
Get Silverman Score
Listen to breath sounds
Get Sp02
Get more history on the mom
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Baby has an APGAR of 8 [lost points for
color]
Baby’s Sp02 is 75% then rises to 85%
within a few minutes with 30% 02 blow by
Silverman is 6
Breath sounds show diffuse crackles in the
bases.
Mom is 28 year-old WF G1 P0

What else do you want to assess?
answer
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VS: RR 65 bpm, HR 135 bpm
X-Ray
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Cardiomegally, and diffuse alveolar infiltrates
and increased hilar markings. Plural effusion
in the RLL
Blood gas:
pH 7. 34
 PC02 33
 P02 53 torr
 Fi02 30% by hood

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What do you want to do?
answer
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Increase the Fi02 from 30% to 35% and
recheck the pulse ox. Continue to raise the
Fi02 until the Sp02 is above 90%
The C02 is ok, but repeat the ABG if the
increased Fi02 doesn’t help the Sp02.
If the Fi02 rises above 40% repeat a
Blood gas to assess the need for CPAP

What is a likely diagnosis with this infant?
answer
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If he gets better in the next 6 hours, we
can assume he has TTN
If he gets worse , he might have mild
HMD
Consider cardiology consult if the
cardiomegally doesn’t resolve in a few
hours
Case study # 5
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L & D RCP calls you. She is doing CPR on
a post-term infant who has APGARs of 1 at
1 & 4 at 5. They did chest compressions
for 8 minutes before the child responded.
What else do you need to know about this
patient?
answer
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What is the mom’s history?
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What is the history of the pregnancy
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18 year old G1 P0
No known problems
What is the history of the delivery?
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Spontaneous breech birth, No PROM, but late
decells in the last few minutes of labor
Greenish black colored amniotic fluid

What do you hope the RCP did in L & D?
answer
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You hope she suctioned below the cords
before the baby took the first breath

Why?
answer
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You hope she got all the meconium out of
the airway because it can cause:
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Bacterial infection
Chemical pneumonitis
Airtrapping and pneumothorax

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The baby is SGA term infant who presents
in the NICI entubated with a 3.0
endotracheal tube. She is being bagged at
a rate of 40 bpm at a PIP of 14 and an
Fi02 50%.
How do you assess her?
answer
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We need to listen to breath sounds to
make sure she has plenty of time to
exhale
We need ABG to assess effectiveness of
her current settings
We need a chest x-ray to assess the
airtrapping
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The doctor orders a blood gas on the right
radial and one off the left.
What is the reason for this action and
what would be significant results?
answer
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We need pre and post-ductal Pa02 to
monitor to r/o right to left shunting and
persistent fetal circulation [PFC].
If there is more than 15 torr difference
then we have:

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Patent ductus arteriosus due to low Pa02
Pulmonary HTN due to low PA02
FO can reopen due to increased RA pressure
Patient will have PFC

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The Pa02 on the right radial is 75 torr and
the Pa02 on the left radial is 58 torr
How do we treat this patient?
answer

Treat PFC with increased ventilation to flip
the patient into respiratory alkalosis and
increase the Fi02 to get the Pa02 above
60 so that the ductus can close and you
can reverse pulmonary HTN

While doing what you have to do to
reverse the PFC, Do you see any problems
with this particular infant?
answer

Yes, this infant should be ventilated
conservatively to prevent a tension
pneumonthorax but we have to reverse
the PFC.