CASE CONFERENCE

WEDNESDAY NIGHT, AUGUST

31TH, 2017
Adam Md/Fatma MD
Eddy MD/Ifa MD/Galih MD/Delfia MD/Indra MD/David MD
Guntur MD/Laras MD
Labiq MD/Anin MD
 PATIENT ADMISSION
Melati 2
1. Child P, 7 y.o, 24 kg with Anterior epistaxis due to Hemophilia A, Hemophilia A, Well
nourished
2. Child J, 9 y.o, 20 kg with Hyperleukocytosis, Acute Leukemia Lymphoblastic (ALL) L2 High
risk Induction Phase Week 0, Well nourished
HCU Neonatus
1. Baby Mrs A, Boy, 29 days, 3500 grams with Neonatal sepsis late onset;
Pneumonia; Hypoalbuminemia due to sepsis; A neonate, boy, normal
birthweight and appropriate for gestational age; vacum extraction delivery
from other hospital
NICU
-
Pediatric HCU
-
PICU
-
 IDENTITY

Name : Baby Mrs. A

Age/W/L : 29 day/ 3500 grams / 50 cm
Sex/Gender : Boy
Address : Karang Anyar , Central Java
Medical : 01390422
Record
 CHIEF COMPLAINT:
FEVER
referred from private general hospital
with Neonatal sepsis late onset
 THE CURRENT MEDICAL HISTORY

• Patient was born from a 30 years old mother G1P1A0 with

37-38 weeks of gestational age. The mother of the patient
than get examined with result blood pressure 120/80
mmHg. The baby was born with 3100 gram of birth weight,
cried loudly, looked reddish, clear amniotic. APGAR score 7-
8-9. Patient was discharge from previous hospital.
• According to his mother, 2 weeks before, he got fever, no
cough and cold, no seizure also. He got medication from
pediatric, but the fever still continous, he began to have cold
and dyspnoe.
 THE CURRENT MEDICAL HISTORY

• Four days before reffered to RSDM, his stomach got bigger and
his scrotum also, still biigger
• He hospitalized for 3 days at Private Hospital, and got red blood
transfusion 80 ml, albumin 25% transfusion 20 ml, and NaCl 3%
150ml corrected. He still abdomen enlargement, he could
defecation, no abdominal pain, no vomitted, no icteric
• The patient used feeding tube (OGT) and it’s product was brown
• During at the hospitalization He got fever for 2 days , no cough
and cold, no seizure.
• Because of no improvement, the patient referred to RSDM
 THE CURRENT MEDICAL HISTORY

• During at the hospitalization, he got fever for 2 days  high fever

and continously. Still got abdominal enlargement and scrotal
enlargement, no cough and runny nose, no seizure, no icteric
• Because of no improvement, the patient referred to Moewardi
General Hospital.
• In ER  patient got lethargy, breathlessness, abdominal
enlargement, cyanotic and scrotal edema. No fever, no vomitted,
no icteric.
 HISTORY OF PREGNANCY AND DELIVERY

Pregnancy
The baby is the first child of his family. Gestational age is 37-38 weeks. The
mother took vitamins and pills routinely from a midwife. According to the
mother, she took routine check up to the midwife monthly. There were no
history of admission to the hospital during the course of pregnancy. No history
of hypertension, icteric, massive edema, vaginal bleeding, leucorhea and fever
during delivery.

Delivery
The baby was delivered by Vacum Extraction. There were no complication during
procedure.When he was born the baby spontaneously open his eyes, looked
active and cry vigourously . The baby weighed at 3100 grams and 50 cm in length.

Conclusion : pregnancy and delivery history were normal

8
 VACCINATION HISTORY

• Hepatitis B : (+) shortly after birth

9
 PEDIGREE (FAMILY TREE)

II

37th 30th

III
29 day, 3500 grams
 NUTRITIONAL STATUS

BB/U : (Z score = 0 SD) Normoweight

TB/U : (-2 SD < Z score < 0 SD), Normoheight
BB/TB : (0 SD < Z score < 2 SD), Well nourished

Conclusion : well nourished, normoweight, normoheight (

based on WHO 2006 growth chart)
 PHYSICAL EXAMINATION
Issues Fever , dyspnea, scrotal edema (+), ascites, sclerema (+)

I
CNS Cry vigorously (+) Active in motion (+) spontaneously open eyes (+)
Assessment: S4
Cardiovascular Heart rate : 145x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate: 88 x/minute, head bobbing (-) Si02 : 85%. Down Score: 4
System Retraction (+) subcostal, nasal flares (+)
Air entry (+) grunting (-), cyanotic (+)
Downe score (4)
II Assessment : moderate respiratory distress
GIT Hepatal Distended (+), undulation (+), defecation(+), peristaltic sound (+)
System 39thdecreased, vomit (-), icteric (-), venectation (+)
34th
Bloody and black discharge product from OGT
Assessment : ascites
III
Genitourinaria Urination (-), edema of scrotal (+)
System Assessment: 8scrotal
thn edema
Infection Thermoregulation System Gastrointestinal System Assessment:
3hari /3800gram
System 36,40C (-) (+) Neonatal sepsis
Central nervous system (+) Hematology System (+) Ascites
CLINICAL APPEARANCE
 LABORATORY RESULTS (31/8/17)

 Hemoglobin = 12.1 g/dl

 Hematocyrte = 35 %
 Leucocyte count = 6.200 /uL
 Thrombocyte count = 48.000 /uL
 Erythrocytes count = 4.29 million /uL
 MCV = 81.5 / um
 MCH = 28.2 pg
 MCHC = 34.6 g/dL
 RDW = 19.1 %
 MPV = 7.3 FL
 PDW = 21%
 Eos/Bas/Neut/Limf/Mono = 1.2%/1.6%/73.9%/21.6%/1.7%
 LABORATORY RESULTS (31/8/17)

 Blood Glucose = 90 mg/dL

 Albumin = 2.6 g/dL
 Sodium = 129 mmol/L
 Potassium = 3.6 mmol/L
 Calcium = 1.31 mmol/L
 PT = 125.2
 APPT = 248.7 u/L

 Conclusion:
Normocytic normochromic anemia, thrombocytopenia, hyponatremia,
hypocalsemia, prolonged of PT and aPPT
 B ABYGRAM

Conclusion:
1. Bronchopneumonia
2. Gastric Tube With VL 1 Left projection
3. Hepatomegaly
4. Ascites
 DIC SCORE

• Platelet count (48,000/uL) :2

• Increase infibrinogen and fibrin-related marker : hasn’t been
evaluated
• Prolonged prothrombine time :1
• Fibrinogen : hasn’t been evaluated
 PROBLEMS

A boy newborn, 29 day, 3500 grams, with:

1. He born by vacum extraction delivery with appropiate gestational age
2. Born with APGAR Score 7-8-9
3. Fever
4. Abdominal enlargement, scrotal edema
5. No cough, runny nose, vomitted, icteric and cyanotic
6. Look dyspnea
7. Product of OGT was brown and blood
8. Lethargy
9. CNS status: S4
10. Downe score 4
11. Ascites, hepatomegaly
12. Sclerema (+)
13. Normocytic normochromic anemia
14. Thrombocytopenia
15. Hyponatremia, hypocalsemia
16. Prolonged of PT and aPTT
17. DIC score 3
18. Baby gram: pneumonia, hepatomegaly, ascites
 DIFFERENTIAL DIAGNOSIS

1. Neonatal sepsis late onset

2. Pneumonia
3. Moderate respiratory disorders due to pneumonia
4. Gastrointestinal bleeding due to sepsis dd DIC
5. Suspected Disseminated intravascular coagulation (DIC)
6. Hypoalbuminemia due to sepsis
7. Normocytic normochromic anemia due to infection process
8. Thrombocytopenia due to sepsis, DIC
9. Hyponatremia
10. Well nourished
 WORKING DIAGNOSIS

1. Neonatal sepsis late onset

2. Pneumonia
3. Moderate respiratory disorders due to pneumonia
4. Gastrointestinal bleeding due to sepsis dd DIC
5. Suspected Disseminated intravascular coagulation (DIC)
6. Hypoalbuminemia due to sepsis
7. Normocytic normochromic anemia due to infection process
8. Thrombocytopenia due to sepsis, DIC
9. Hyponatremia
10. Well nourished
 THERAPY

1. Admitted to Neonatal High Care Unit

2. Temporary fasting  OGT product
3. Nasal O2 1 liter per minutes
4. IVFD KAEN 1B 15ml/hr iv
5. Cefoperazon Sulbactam inj ( 50mg/kgbw/8H)  175mg/12hour iv
6. Gentamicin inj (5mg/kgbw/24H) 18mg/hour iv
7. Paracetamol Injection (15mg/kgBW/ 8 hour) 40mg/8hour iv
8. Plan for thrombocyte concentrate transfusion 3 pack and Fresh frozen
plasma transfusin 3 pack
9. Plan for albumin transfusion
 PLAN

1. Check GDT IT ratio, hsCRP, Blood culture, Gamma GT, ALP, Bilirubin T/d/i
2. USG abdomen

MONITORING

 General Appearance/Vital Signs / hours

 Fluid balance and Diuresis / 8 hours
 At Neonates HCU , Friday 01 September 2017
Issues Fever , dyspnea worsen, scrotal edema (+), ascites, sclerema (+)

CNS Cry vigorously (+) Active in motion (+) spontaneously open eyes (+)
Assessment: S4
Cardiovascular Heart rate : 170x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 84x/minute, head bobbing (-) Si02 : 85%. Down Score: 5
System Retraction (+) subcostal, nasal flares (+)
Air entry (+) grunting (-), cyanotic (+)
Downe score (5)
Assessment : moderate respiratory distress
GIT Hepatal Distended (+),Undulation (+), defecation(+), peristaltic sound (+) decreased, vomit (-), icteric (-),
System venectation (+), bloody product OGT
Assessment : ascites (+), upper GIT bleeding
Genitourinaria Urine product 80ml during 7 hour
System Assessment: normal
Infection Thermoregulation System 37- Gastrointestinal System (+) Assessment:
System 37,8 C (+)
0 Hematology System (+) sepsis neonatorum
Central nervous system (+) Hemodynamic System (-)
Cardiovascular System (-)
Respiratory System (+)

Fluid requirement 90x 4,1= 369ml/day

Calories needs 120 x 4,1 =492 kkal/day
 WORKING DIAGNOSIS

1. Sepsis neonatorum
2. Pneumonia
3. Moderate respiratory disorders due to pneumonia
4. Gastrointestinal bleeding due to sepsis dd DIC
5. Suspected Disseminated intravascular coagulation (DIC)
6. Hypoalbuminemia due to Sepsis
7. Normocytic normochromic anemia due to infection process
8. Thrombocytopenia due to sepsis
9. Hyponatremia
10. Well nourished
 THERAPY
1. Temporary fasting  evaluate OGT product
2. Oxygenation with CPAP (PEEP: 4 cmH2O, flow 40%)
3. IVFD D13%: D 1/4NS 175ml + D40% 44,5ml+KCL 2ml+ Ca gluconas 2
ml+soluvit 2ml = 9,4 ml/ hour (GIR 5)
4. Aminosteril 6% inf ( 1gr/kgbW/day) 68 ml/day= 2,8 ml/hour
5. Lipofundin 20% inf ( 1gr/kgbW/day) 20,5 ml/day= 0,8ml/hour
6. Cefoperazon Sulbactam inj ( 50mg/kgbw/8H)  175mg/12hour iv
7. Gentamicin inj (5mg/kgbw/24H)-18mg/24 hour
8. Sucralfat spooling 3ml/8 hour
9. Ranitidine inj loading 1,5mg/kgBW ; 6mg, then 1mg/kgBW/12 hour : 4mg/12 hour
iv
10. Plan for thrombocyte concentrate transfusion 3 pack and Fresh frozen plasma
transfusin 3 pack (@80ml) intervally
11. Plasbumin transfusion: plasbumin 25% 25ml
 PLAN

1. Check GDT IT ratio, hsCRP, Blood culture, Gamma GT, ALP, Bilirubin T/d/i
2. USG abdomen
3. Urinalysis, and stool analysis

MONITORING

 General Appearance/Vital Signs / hours

 Fluid balance and Diuresis / 8 hours
 Follow Up, Saturday 02 September 2017
Issues Fever + Sepsis Late Onset

I
CNS Cry vigorously (+) Active in motion (+) spontaneously open eyes (+)
Assessment: S5
Cardiovascular Heart rate : 120x/minute
System Murmur (-), capillary refill time < 2 seconds, dorsalis artery pulse (+)
Assessment: no abnormality
Respiratory Respiratory rate : 92 x/minute, head bobbing (-) Si02 : 90%. Down Score: 3
System Retraction (+) subcostal
Air entry (+) grunting (-), cyanotic (-)
Downe score (3)
II Assessment : no abnormally
GIT Hepatal Distended (+),Undulation (+), defecation(+), peristaltic sound (+)
System 39thdecreased, vomit (-), icteric (-), 34th
Assessment :
Genitourinaria Urination (-)
III
System Assessment: not yet to be evaluated
Infection 8 thnSystem
Thermoregulation Gastrointestinal System Assessment: No. potential
System 36,40C (-) (-) infection
3hari
Central nervous system (-) /3800gram
Hematologyy System (-)
Cardiovascular System (-) Hemodynamic System (-
 WORKING DIAGNOSIS

1. Neonatal sepsis late onset

2. Pneumonia
3. Moderate respiratory disorders due to pneumonia
4. Gastrointestinal bleeding due to sepsis dd DIC
5. Disseminated intravascular coagulation (DIC) due to sepsis
6. Hypoalbuminemia due to sepsis
7. Normocytic normochromic anemia due to infection process
8. Thrombocytopenia due to sepsis, DIC
9. Hyponatremia
10. Well nourished
 THERAPY
1. Temporary fasting  evaluate OGT product
2. Oxygenation with CPAP (PEEP: 4 cmH2O, flow 40%)
3. IVFD D13%: D 1/4NS 175ml + D40% 44,5ml+KCL 2ml+ Ca gluconas 2
ml+soluvit 2ml = 9,4 ml/ hour (GIR 5)
4. Aminosteril 6% inf ( 1gr/kgbW/day) 68 ml/day= 2,8 ml/hour
5. Lipofundin 20% inf ( 1gr/kgbW/day) 20,5 ml/day= 0,8ml/hour
6. Cefoperazon Sulbactam inj ( 50mg/kgbw/8H)  175mg/12hour iv
7. Gentamicin inj (5mg/kgbw/24H)-18mg/24 hour
8. Sucralfat spooling 3ml/8 hour
9. Ranitidine inj loading 1,5mg/kgBW ; 6mg, then 1mg/kgBW/12 hour : 4mg/12 hour
iv
10. Plan for thrombocyte concentrate transfusion 3 pack and Fresh frozen plasma
transfusin 3 pack (@80ml) intervally
11. Plasbumin transfusion: plasbumin 25% 25ml
 PLAN

1. Check GDT IT ratio, hsCRP, Blood culture, Gamma GT, ALP, Bilirubin T/d/i
2. USG abdomen
3. Urinalysis, and stool analysis

MONITORING

 General Appearance/Vital Signs / hours

 Fluid balance and Diuresis / 8 hours
 HOW TO PREDICT OF NEONATAL SEPSIS ?

• P : neonatal sepsis
• I : biomarker of sepsis
• C : blood culture
• O : predict of neonatal sepsis
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