General Information
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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
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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
• Post-op wound
with surrounding
erythema, which
continuously
draining fecaloid
discharge
• (+) fever
• Poor suck and
activity
two hours PTA
ADMISSION
Review of Systems
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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
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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
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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
2
y/o
2mos
No history of
Hypertension, DM,
Bronchial Asthma,
Allergy, Malignancy,
Seizure disorder
Immunization History
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BCG x 1 dose
Hep B x 1 dose
Nutritional History
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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
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Gross motor
 Poor
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head control
Language
 coos
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Fine motor
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fisting
Personal Social
 No
social smile
Personal Social History
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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
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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
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General Survey: awake, not in respiratory distress
Wt: 2.0 kg (z score: <-2 )
VS:
 Temp
36.0
 CR 122
 RR: 41
Physical examination
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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
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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, HealthcareAcquired Infection
Course in the Wards
Course in the wards 1st HD
S/O
P
6:00 AM
Seen by Surgery at ER
Admit to Surgery Ward
NPO
D5LR mild for 6 hours
PLR vol/vol replacement
PRBC (10ml/kg/aliq) x 3
Therapeutics
• Refer to PIDS for
Meropenem (60)
• Insert OGT, cutdown
• Refer to Gastro Service
for comanagement
Cbc:
Hgb: 67
Hct: 20
8:00 AM
WBC: 22
Weak looking, sunken
Segmenters: 70
fontanels, sunken eyeballs Lymph: 26
(+) fecaloid material over Mono: 4
post-op site
Platelets: 218
• Wound GS, CS
• Blood CS
Course in the wards 2nd HD
S/O
Awake
Not in distress
Flat fontanels
Pink conjunctiva, anicteric
sclerae, isocoric pupils
(+) fecaloid material
approximately 20ml
Full and equal pulses
UO 5.1ml/kg/hr
P
• Wound GS, CS
• Blood CS
Post PRBC Cbc:
Hgb: 142
Hct: 42
WBC: 19.6
Segmenters: 64
Lymph: 33
Platelets: 163
NPO
D5IMB (Mtn)
PLR vol/vol replacement
s/p PRBC (10ml/kg/aliq) x 3
Therapeutics
• Meropenem (60)
• Mupirocin ointment on
affected areas
• Updated Gastro Service,
for formal referral
Course in the wards 3rd HD
S/O
Awake
Not in distress
Flat fontanels
Pink conjunctiva, anicteric
sclerae, isocoric pupils
(+) fistula output 30ml
Full and equal pulses
UO 3.4ml/kg/hr
(+) hypoglycemic
episodes, s/p 2 doses of
D10W (5) IV bolus
P
• 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
Awake
Not in distress
Flat fontanels
Pink conjunctiva, anicteric
sclerae, isocoric pupils
(+) fecaloid material
approximately 30ml
Full and equal pulses
FB +309
UO 12.2 ml/kg/hr
(+) hypoglycemic
episodes, s/p 2 doses of
D10W (5) IV bolus
P
Awaiting funds for
• Wound CS
• Blood CS
Post PRBC Cbc:
Hgb: 119
Hct: 35
WBC: 12
Segmenters: 61
Lymph: 28
Monocytes: 11
Platelets: 140
Urine KOH
NBS
s/p removal of MESH, postop Day 1
NPO
No 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
Awake
Awaiting funds for
Not in distress
• Wound CS
Flat fontanels
• Blood CS
Pink conjunctiva, anicteric
sclerae, isocoric pupils
Intact post-op dressing, no
fecaloid material
Full and equal pulses
UO 13.4 ml/kg/hr
(+) hypoglycemic
episodes, s/p 2 doses of
D10W (5) IV bolus
s/p removal of MESH, postop Day 2
NPO
No 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 HD
S/O
Awake
Not in distress
Flat fontanels
Pink conjunctiva, anicteric
sclerae, isocoric pupils
Intact post-op dressing, no
fecaloid material
Full and equal pulses
FB -25
UO 10.4 ml/kg/hr
(+) hypoglycemic
episodes, s/p 2 doses of
D10W (5) IV bolus
P
Awaiting funds for
• Wound CS
• Blood CS
Electrolytes:
Na 142, K 4.9, Cl
116, Ca 2.33
s/p removal of MESH, postop Day 2
Start Milk Formula 5cc q6
via OGT
No funds for TPN; D12.5IMB
(mtn)
PLR vol/vol replacement
Meropenem Day 6
GASTRO: Facilitate TPN,
rectal stimulation
Course in the wards 8th HD
S/O
(+) hypoglycemic
episodes, s/p 2 doses of
D10W (5) IV bolus
(+) septic shock
P
CBC
Electrolytes
PT
APTT
Random urine
sodium
post-op Day 4
O2 at 10LPM
Referred to ICU
Meropenem Day 8, with
missed doses
Referred back to PIDS for
Fluconazole use
-Started on Ciprofloxacin,
Metronidazole, Amphotericin,
Vancomycin
Course in the wards 9th HD
S/O
11:00Am
Asleep, but arousable
(+) still with episodes of
hypothermia and
hypoglycemia
(+) abdominal distention
Hypoactive bowel sounds
(+) bleeding on previous
extraction site
A: Septic shock, T/C DIC
secondary to Sepsis
P
PT 15.2, 11.2, 56.6,
1.36
APTT 43.9, 27.5
PNSS at 20cc/kg
For PRBC
For FFP
Continue IV antibiotics
Cipro d2
Metro d2
Ampho d2
Vanco d2
Keep thermoregulated
For Serum electrolytes
Course in the wards 10th HD
S/O
P
10:00pm
Drowsy, but arousable
CR: 90 RR: 30 O2 sat: 93% Temp 34
 36.5C
(-)alar flaring
Shallow subcostal retractions and
intercostal retractions
Clear breath sounds
Globular abdomen, hypoactive bowel
sounds, Soft abdomen
Fair pulses, cold extremities
(+) bleeding on previous IV sites
CRT <2 secs
Pupils 2-3 EBRTL
Thermoregulated
Hook to cardiac monitor
Hook to O2 at 10LPM
Keep thermoregulated
For Chest xray to include
abdomen
For ABG
Still for blood CS, serum
elec, PT, PTT
For intubation
(Appraised parents)
Course in the wards
S/O
P
11:25 pm
Pupils Sluggishly reactive to light
Pupils anisocoric, Gasping, CR: 80s
Poor Pulses, cold ext
BP: 0
CR: 30-40, gasping , T:34C
poor pulses
CRT 3 seconds
Cold ext
For intubation
Start High Quality CPR
PNSS (20cc/kg) Bolus
Give Epi (1:10,000) 0.19
cc IV
ICU updated
Course in the wards
S/O
11:25 pm
BP: 0 CR: 0, RR: 0 , T:35
CRT: 3-4 seconds
Poor pulses, cold ext
9/17/2014
12:00 AM
Dilated pupils
CR: 0 RR: 0
No pulses
P
Continue High quality CPR
Give another PNSS
(20cc/kg) Bolus
Give Epi (1:10,000) 0.19
cc IV x 6 doses every 2
minutes
Pronounced dead
Render post mortem care
Autopsy offered but
refused
Final Diagnosis
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Septic Shock
Disseminated Intravascular Coagulation
Healthcare Acquired Infection
Failure to thrive