Pediatric Case Management

1
Pediatric Case Management

• Joseph Wiley, MD
• Cynthia Roldan, MD
• December 20, 2005

2
December Cases-Ward

• 12 yo female with headaches and mental status
  changes (transfer)
• 15 yo female with abdominal pain, b/l pulmonary
  nodules likely autoimmune in origin (transfer)
• 4 month old ex premie with h/o NEC readmitted for
  abdominal distension

3
December Cases-PICU

• 20 month old female with pneumonia and pleural
  effusions transferred to floor, and developed
  pneumothorax post chest tube removal (morbidity)

4
Follow up Case

• 4 month old female ex 30 week premature infant
  presented with ALTE
• History of apnea, reflux, developmental delay,
  seizures
• Admitted for work-up (9 day hospitalization)
• CV
• Neuro-normal MRI, EEG
• GI-Reflux

5
Hospital Course

• Discharged with diagnosis of Reflux
• apnea monitor with reflux precautions and
  medications,
• Neurology follow up

6
Follow up-contd.

• 4 days after discharge, found face down in crib,
  not breathing-with blanket over head
• EMS found baby apneic and pulseless
• Resuscitated after 45 minutes w/o spontaneous
  circulation
• Expired Autopsy report
• Died of complications of Prematurity cause of
  apnea and seizure not found
• Manner of death natural

7
CASE MANAGEMENT

• Jamie Lanzillotta, D.O.
• December 20, 2005

8
Baby Girl W

• 36 6/7 week Caucasian female
• Prenatal/maternal history
• 22 y.o G2 P1001
• Prenatal care since 6 wks
• All labs normal, GBS unknown
• Uncomplicated pregnancy until day prior to
  delivery

9
Prenatal History

• Day prior to delivery _at_ OB visit
• 14 lb wt gain in 2 wks
• Fundal Ht-44 cm
• Bedside ultrasound
• -Polyhydramnios
• -Pleural effusions b/l
• -Hydrops

10
Delivery History

• Induced
• Vaginal delivery attempted with vacuum
  assist?unsuccessful
• Emergent c-section
• Appearance before resuscitation
• Blue, edematous, no respiratory effort, HRlt100

11
Resuscitation

• Intubated
• UV line placed
• Epinephrine x 1 IV
• HR improved gt100
• NICU
• Chest tubes placed b/l
• gt500 cc serosanguinous drainage

12
Initial Chest film
No visible lung fields
No visible lung fields
13
Follow up films
Large pneumothorax with subcutaneous air
After chest tubes x 3
14
Physical exam

• T 35.6 P 113 RR 50 BP 53/32 MAP 34
• Wt 4.060 kg HC 36 cm Length 46.5 cm

15
DIFFUSE EDEMA
16
Initial labs
100
16.9
139 105 13
31.5
174
50
3.7 25 0.9
10.3
Pleural fluid 2980 WBC Lactate 5.7 1430
RBC Protein 1542 Glucose 70
Gram stain -
ABG 7.01/86/46/22/-12
Subsequent Labs Chromosomes-Normal,
All viral studiesnegative
17
Assessment/Plan

• 36 6/7 wk female with b/l pleural effusions
  hydrops
• Plan
• D15 _at_ 50 cc/kg/day
• Oscillator for ventilation- Q2 gasses
• Stat echo
• Ampicillin/Gentamicin
• Dopamine _at_ 2 mcg/kg/min
• CXR q 6
• Chromosomes, viral cultures
• Genetics consult

18
Hospital Course

• Respiratory
• On oscillator throughout course
• Chest tube output-500 cc/day
• Developed
• Pneumothoraces requiring additional
• chest tubes
• PPHN-placed on nitric oxide _at_ 20 ppm

19
Hospital Course, contd.

• Cardiovascular
• Required pressor support with dopamine
• Echocardiogram- nl function, nl anatomy _at_ Sinai
• _at_ hopkins-Interrupted Inferior Venae Cava w/
  right azygous continuation to right SVC
• ID
• All cultures-negative to date
• Received 48 hrs of abx
• Heme
• Required PRBCs
• Abnormal coagulation profile suggesting DIC

20
Hospital course, contd.

• FEN
• Albumin cc/cc for chest tube replacement
• Ca gluconate
• IVF TPN
• GU
• Poor urine output until Day 2
• Urine grossly bloody

21
Albumin Levels
22
Genetics Consult-Recommendations

• Chromosomes? nl
• Limited secondary to inadequate number of cells
  cultured
• Hemoglobin electrophoresis
• Urine
• mucopolysaccarides
• sialic acid
• Iron, Ferritin

23
Hospital course continued..

• DOL4
• Unable to maintain sats on maximum vent settings
• Hypotension despite pressor support
• Transferred to Hopkins to be placed on ECMO
• Died before ECMO could be initiated

24
Initial A-a Gradients
A-a gradient gt600?Indication for ECMO
25
A-a gradients 24 hrs prior to transfer
A-a gradient gt600?Indication for ECMO
26
Discussion -Non Immune Hydrops Fetalis (NIHF)

• Epidemiology
• Management
• Indications for ECMO
• Role of ECMO in treatment

27
Points of Discussion

• Questions
• Did the patient meet criteria for starting ECMO
  several hours before transfer occurred?
• Would starting ECMO sooner have improved her
  chance of survival?

28
Epidemiology- NIHF

• 1 in 2,500?4,000 pregnancies
• Varies by population
• More common in SE Asian population (homozygous
  alpha thalassemia)
• Mortality-50

29
Management-in utero

• Management depends on etiology-Examples

30
Neonatal management

• Resuscitation in DR-Intubation, UV line
  placement, Chest tube placement
• ?Surfactant
• Echocardiogram
• Abdominal and cranial ultrasound
• Genetics consultation
• Fluid restriction
• Albumin to increase oncotic pressure
• Broad spectrum antibiotics
• Pressor support as needed
• Octreotide-if chylothorax
• ECMO

31
Qualifying Criteria for ECMO

• A-a Gradient 600-624 for 4-12 hrs
• Oxygenation index gt40 in 3 of 5 postductal gasses
  30-60 minutes apart
• PaO2- 35-50 mm Hg for 2-12 hours
• Acute deterioration
• PaO2lt30-40 mm Hg for 2 hours
• pH lt7.25 for 2 hours
• Intractable hypotension

32
ECMO And Hydrops

• Retrospective chart review
• 24 hydropic babies with no etiology
  (non-immune)

13 Survivors
11 Non-survivors
2 groups compared using 10 criteria Conclusion
Major difference between 2 groups? Time lapsed
before ECMO initiated was greater in non-survivor
group Bealer, John. Journal of Pediatric
Surgery. 1997. 321645-1647.
33
Comparison Data
34
References

• www.e-medicine.com
• Chescheir, Nancy. Management of Hydrops Fetalis.
  (article provided by Dr. OBrien-unknown text)
• Murphy, Janet. Nonimmune Hydrops Fetalis. Neo
  Reviews. 2004. Volume 55-15.
• Bealer, John. Journal of Pediatric Surgery.
  1997. 321645-1647.