CHAPTER I INTRODUCTION 1.1 Background Neonatal sepsis may be categorized as early-onset or late-onset. Of newborns with early-onset sepsis, 85% present within 24 hours, 5% present at 24-48 hours, and a smaller percentage present within 48-72 hours. Onset is most rapid in premature neonates. Early-onset sepsis is associated with acquisition of microorganisms from the mother. Transplacental infection or an ascending infection from the cervix may be caused by organisms that colonize the mother’s genitourinary tract. The neonate acquires the microorganisms as it passes through the colonized birth canal at delivery. The microorganisms most commonly associated with early-onset infection include Group B Streptococcus (GBS), escherichia coli, coagulase-negative Staphylococcus, Haemophilus influenzae, and Listeria monocytogenes. 1 Late-onset sepsis occurs at 4-90 days of life and is acquired from the caregiving environment. Organisms that have been implicated in causing late-onset sepsis include : Coagulase-negative Staphylococcus, Staphylococcus aureus, E coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter, and Anaerobes. 2 1
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CHAPTER I
INTRODUCTION
1.1 Background
Neonatal sepsis may be categorized as early-onset or late-onset. Of newborns with
early-onset sepsis, 85% present within 24 hours, 5% present at 24-48 hours, and a smaller
percentage present within 48-72 hours. Onset is most rapid in premature neonates.
Early-onset sepsis is associated with acquisition of microorganisms from the
mother. Transplacental infection or an ascending infection from the cervix may be caused by
organisms that colonize the mother’s genitourinary tract. The neonate acquires the
microorganisms as it passes through the colonized birth canal at delivery. The
microorganisms most commonly associated with early-onset infection include Group B
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca Gluconas
10 cc = 12 gtt/I (micro)
o Enteral : 50 cc/BW/day = 154 cc/day
Breast milk : 12 cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
Hiponatremia Correction:
o Deficiency : (135-127)x 0,6x 3 = 14,4 mEq
o Maintance: 2-4 mEq/BW = 6-12 mEq/day
o Total : 25 mEq/day
Fluid correction : D 5% NaCl 0,45% (430 cc) + D 40% (70cc)+ KCl 10 mEq + Ca
Gluconas 10 cc = 13 gtt/I (micro)
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Follow up
May 5th , 2013
S : faint (+), inactive movement (+)
O: Sens: CM, Temp: 37,1oC. Body weight : 3082 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear/nose/mouth: normal in appearance
Thorax Simetrical fusiform, no retraction
HR: 124 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 40 rpm, regular, no rales, O2 saturation 98 %
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pulse 124bpm, regular, pressure and volume were adequate, CRT <3”,
muscle tone ↓
A : Postterm neonates- appropriate for gestational age + suspect sepsis + dextrocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day
o Parenteral : 100 cc/BW/day = 300 cc/day
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca Gluconas 10 cc = 12 gtt/I (micro)
o Enteral : 50 cc/BW/day = 154 cc/day
Breast milk : 12cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
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Laboratorium Finding :
Electrolyte
Natrium (Na) mEq/L 138 135-155
Kalium (K) mEq/L 4.9 3.6-5.5
Chloride (Cl) mEq/L 109 96-106
Chest X-ray : infiltrate(-) & the patient’s right sided heart
May 6th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 37oC. Body weight : 3030 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : O2 nasal canule (+). Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 90 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 44 rpm, regular, no rales, no stridor, O2 saturation : 98 %
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities pressure and volume were adequate, CRT <3” & warm extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + dextrocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 454,5 cc/day
o Parenteral : 90 cc/BW/day = 272,7 cc/day
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 11 gtt/I (micro)
o Enteral : 70 cc/BW/day = 212 cc/day
33
Breast milk : 18cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
Plan :
septic work up
Cardiology consult
Neurology consult
Laboratory Result:
Complete Blood Count (CBC)
Hemoglobin (HGB) g% 17.6 13.4-19.8
Eritrosit (RBC) 106/mm3 4.89 5.33-5.47
Leucocyte (WBC) 103/mm3 5.64 6.0-17.5
Hematokrit % 50.9 51-65
Trombosit (PLT) 103/mm3 280 217-497
MCV fL 104.1 104-116
MCH Pg 36 35-39
MCHC g% 34.60 32-34
RDW % 15.10 14,9-18.7
MPV fL 10.80 7.2-10.0
PCT % 0.30
PDW fL 13.5
LED mm/jam 7 <15
Difftel Count
Neutrofil % 17.3 37-80
Limfosit % 45.9 20-40
Monosit % 29.10 2-8
Eosinofil % 7.3 1-6
Basofil % 0.4 0-1
34
Neutrofil Absolut 103/µL 0.98 5.5-18.3
Limfosit Absolut 103/µL 2.59 2.8-9.3
Monosit Absolut 103/µL 1.64 0.5-1.7
Eosinofil Absolut 103/µL 0.41 0.02-0.70
Basofil Absolut 103/µL 0.02 0.1-0.2
IT Ratio 0.01 <0.2
Liver
Total Bilirubin mg/dl 0.27 <1
Direct Bilirubin mg/dl 0.11 0-0.2
Fosfatase alkali U/L 105 <449
AST/SGOT U/L 131 <38
ALT/SGPT U/L 138 <41
May 7th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,6 oC. Body weight : 3030 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : O2 nasal canule (+). Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 104 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities pressure and volume were adequate, CRT <3” & warm extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + dextrocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
35
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 462 cc/day
o Parenteral : 80 cc/BW/day = 246 cc/day
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 10 gtt/I (micro)
o Enteral : 70 cc/BW/day = 215 cc/day
Breast milk : 18cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
Plan :
EEG
Echocardiography
Laboratory finding :
Electrolyte
Calcium (Ca) mg/dl 9.3 8.4-10.8
Magnesium (Mg) mEq/L 1.87 1.4-1.8
Echocardiography result : Mesocardia
May 8th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,6 oC. Body weight : 3050 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : O2 nasal canule (+). Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 108 bpm, regular, no murmur, stridor (+), right heart sound > left heart
36
sound.
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities pressure and volume were adequate, CRT <3” & warm extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 70 cc/BW/day = 231 cc/day
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 10 gtt/I (micro)
o Enteral : 80 cc/BW/day = 264 cc/day
Breast milk : 22cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
Plan :
EEG
Laboratory Result :
Electrolyte
Calcium (Ca) mg/dl 9.3 8.4-10.8
May 9th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,9 oC. Body weight : 3050 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
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Ear: normal in appearance. Nose : O2 nasal canule (+). Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 142 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 40 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 102 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 70 cc/BW/day = 231 cc/day
IVFD D 5% NaCl 0,9 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 10 gtt/I (micro)
o Enteral : 80 cc/BW/day = 264 cc/day
Breast milk : 22cc/ 2 hours/OGT
Inj Phenobarbital 6 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 15,5 mg/24 hours/IV
May 10th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : O2 nasal canule (+). Mouth : OGT (+)
38
Thorax Simetrical fusiform, no retraction
HR: 120 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 46 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 120 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 198 cc/day
o Parenteral : 60 cc/BW/day = 231 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 8 gtt/I (micro)
o Enteral : 90 cc/BW/day = 297 cc/day
Breast milk : 25cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 16 mg/24 hours/IV
Plan :
Complete Blood Count (CBC)
Folllow Culture result
EEG
May 11th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were
39
not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 136 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 42 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 136 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 50 cc/BW/day = 465 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 7 gtt/I (micro)
o Enteral : 100 cc/BW/day = 330 cc/day
Breast milk : 28cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 16 mg/24 hours/IV
Plan :
Follow blood culture
EEG
Laboratory Result:
EEG Result : General Convulsions disease with multifocal irritative focus.
40
May 12th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 140 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 42 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 140 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 50 cc/BW/day = 465 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 10 cc = 7 gtt/I (micro)
o Enteral : 100 cc/BW/day = 330 cc/day
Breast milk : 28cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 16 mg/24 hours/IV
May 13th , 2013
S : crying weakly (+), inactive movement (+)
41
O: Sens: CM, Temp: 36,8 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : 02 nasal kanul. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 116 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 116 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 40 cc/BW/day = 132 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 6 gtt/I (micro)
o Enteral : 110 cc/BW/day = 363 cc/day
Breast milk : 30 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Gentamycin 16 mg/24 hours/IV
Nystatin 4 x 1 cc
Plan :
Follow blood culture (13/5/2013)
Follow EEG result (13/5/2013)
42
May 14th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,7 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : 02 nasal kanul. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 114 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 48 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 114 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 40 cc/BW/day = 132 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 6 gtt/I (micro)
o Enteral : 110 cc/BW/day = 363 cc/day
Breast milk : 30 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
43
Nebule Nacl 0,9 2,5 cc % /8 jam
Plan :
CBC
Elektrolit ( Na, K, Cl, Ca, Mg )
Laboratory Result:
Complete Blood Count (CBC)
Hemoglobin (HGB) g% 13.20 13.4-19.8
Eritrosit (RBC) 106/mm3 3.82 5.33-5.47
Leucocyte (WBC) 103/mm3 10.69 6.0-17.5
Hematokrit % 39.90 51-65
Trombosit (PLT) 103/mm3 17 217-497
MCV fL 104.50 104-116
MCH Pg 34.60 35-39
MCHC g% 33.10 32-34
RDW % 15.80 14,9-18.7
Difftel Count
Neutrofil % 55.60 37-80
Limfosit % 22.40 20-40
Monosit % 18.40 2-8
Eosinofil % 3.30 1-6
Basofil % 0.300 0-1
Neutrofil Absolut 103/µL 5.95 5.5-18.3
Limfosit Absolut 103/µL 2.39 2.8-9.3
Monosit Absolut 103/µL 1.97 0.5-1.7
Eosinofil Absolut 103/µL 0.35 0.02-0.70
Basofil Absolut 103/µL 0.03 0.1-0.2
Elektrolit
Kalsium (Ca) mg/dl 8.6 8.4 – 10.8
Natrium (Na) mEq/L 136 135 - 155
44
Kalium (K) mEq/L 4.8 3.6 – 5.5
Klorida (Cl) mEq/L 108 96 - 106
Magnesium (Mg) mEq/L 2.25 1,4 – 1,8
Carbohydrate metabolism
Blood Glucose mg/dl 9.3 < 200
Faal Hemostasis
PT + INR
Protrombin Time
Control sekon 14.50
Patient sekon 15,7
INR 1.09
APTT
Control sekon 29.9
Patient Sekon 38.2
Trombin Time
Control sekon 15.5
Patient sekon 19.5
May 15th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,8 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : 02 nasal kanul. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 110 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
45
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 110 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + suspect sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 40 cc/BW/day = 132 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 5 gtt/I (micro)
o Enteral : 110 cc/BW/day = 363 cc/day
Breast milk : 30 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 2,5 cc % /8 jam
May 16th , 2013
S : crying weakly (+), inactive movement (+)
O: Sens: CM, Temp: 36,7 oC. Body weight : 3000 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 120 bpm, regular, no murmur, stridor (+), right heart sound > left heart
46
sound.
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 120 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 40 cc/BW/day = 132 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 6 gtt/I (micro)
o Enteral : 110 cc/BW/day = 363 cc/day
Breast milk : 30 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc /8 jam
May 17th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 36,7 oC. Body weight : 3050 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
47
HR: 132 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 44 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 132 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc /8 jam
May 18th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 37,5 oC. Body weight : 3050 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
48
Thorax Simetrical fusiform, no retraction
HR: 140 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 50 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 140 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc/8 jam
May 19th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3050 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
49
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 140 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 48 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 140 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc/8 jam
May 20th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3020 gr. Dyspnea, cyanosis, icteric and oedema were not present
50
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 140 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 38 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 140 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc/8 jam
51
May 23th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 142 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 40 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 142 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
52
Nebule Nacl 0,9 % 2,5 cc/8 jam
May 24th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 37 oC. Body weight : 3080 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 140 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
RR: 39 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 140 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 33 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
53
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc/8 jam
Plan :
Inj Phenobarbital is given until june 5th 2013 then tapering off
CBC and electrolyte
Laboratory Result:
Complete Blood Count (CBC)
Hemoglobin (HGB) g% 13.20 13.4-19.8
Eritrosit (RBC) 106/mm3 3.82 5.33-5.47
Leucocyte (WBC) 103/mm3 10.69 6.0-17.5
Hematokrit % 39.90 51-65
Trombosit (PLT) 103/mm3 17 217-497
MCV fL 104.50 104-116
MCH Pg 34.60 35-39
MCHC g% 33.10 32-34
RDW % 15.80 14,9-18.7
Difftel Count
Neutrofil % 55.60 37-80
Limfosit % 22.40 20-40
Monosit % 18.40 2-8
Eosinofil % 3.30 1-6
Basofil % 0.300 0-1
Neutrofil Absolut 103/µL 5.95 5.5-18.3
Limfosit Absolut 103/µL 2.39 2.8-9.3
Monosit Absolut 103/µL 1.97 0.5-1.7
Eosinofil Absolut 103/µL 0.35 0.02-0.70
Basofil Absolut 103/µL 0.03 0.1-0.2
Elektrolit
54
Kalsium (Ca) mg/dl 8.6 8.4 – 10.8
Natrium (Na) mEq/L 136 135 - 155
Kalium (K) mEq/L 4.8 3.6 – 5.5
Klorida (Cl) mEq/L 108 96 - 106
Magnesium (Mg) mEq/L 2.25 1,4 – 1,8
Carbohydrate metabolism
Glukosa Darah (Sewaktu) mg/dl 9.3 < 200
Faal Hemostasis
PT + INR
Protrombin Time
control sekon 14.50
Patient sekon 15,7
INR 1.09
APTT
Control sekon 29.9
Patient sekon 38.2
Trombin Time
Control sekon 15.5
Patient sekon 19.5
May 25th , 2013
S : crying weakly (+), active movement (+)
O: Sens: CM, Temp: 36,9 oC. Body weight : 3100 gr. Dyspnea, cyanosis, icteric and oedema were not present
Head Eyes: conjunctiva palpebra’s pale (-). Light reflex: +/+, isocoric pupil,
Ear: normal in appearance. Nose : normal in appearance. Mouth : OGT (+)
Thorax Simetrical fusiform, no retraction
HR: 148 bpm, regular, no murmur, stridor (+), right heart sound > left heart
sound.
55
RR: 36 rpm, regular, no rales, no stridor
Abdomen Soepel, peristaltic (+) normal,
liver/spleen/renal: indeterminate
Extremities Pols 148 bpm, pressure and volume were adequate, CRT <3” & warm
extremities
A : Postterm neonates- appropriate for gestational age + unproven sepsis + mesocardia + neonatal seizure ec DD(HIE/Intracranial hemorrhage)
P :
Keep in radiant infant warmer
Total fluid requiment : 150 cc/BW/day = 495 cc/day
o Parenteral : 30 cc/BW/day = 99 cc/day
IVFD D 5% NaCl 0,225 % (430 cc) + D 40% (70cc) +KCl 10 mEq + Ca
Gluconas 20 cc = 4 gtt/I (micro)
o Enteral : 120 cc/BW/day = 396 cc/day
Breast milk : 35 cc/ 2 hours/OGT
Inj Phenobarbital 7,5 mg/12 hours/IV
Inj Ceftazidine 155 mg/ 12 hours/ IV
Inj Amikasin 25 mg/8 hours/IV
Nystatin 4 x 1 cc
Ezera Gel 4 x 1 Applic
Nebule Nacl 0,9 % 2,5 cc/8 jam
56
CHAPTER 4
DISCUSSION AND SUMMARIES
4.1. Discussion
A 8 days old girl (DS/MR 55 81 29) was admitted at May 4 th, 2013 to Haji Adam Malik
General Hospital. Her parents complained that their baby was no movement respond since was
born and has generalized seizure since was born. The abnormality of the heart was found when
she had thorax X-ray. Clinical examination and laboratory diagnose was established and she
was been diagnosed with postterm neonates-appropriate for gestational age with unproven
sepsis plus mesocardia and neonatal seizure ec DD(HIE/Intracranial hemorrhage).
The patient hasn’t had clinical presentation of repetitive seizure for long period of time. It’s
related to theory that neonatal seizures tend to be brief, because immature neurons are unable to
sustain repetitive activity for long period of time and to be focal or multifocal. After that, in this
patient, we found her no immediate cry when was born. This can make the baby asphyxia.
Consequently, patients may experience seizure. It's related with the theory that the leading cause
of neonatal seizures is cerebral hypoxia-ischemia
We can also found in this patients with clinical symptoms are staring, sustained vertical or
horizontal deviation of the eyes and sustained flexion upper limbs. It’s related with the theory
that the most common manifestations in neonatal seizure are from ocular, they are usually
consisting of staring, horizontal or vertical sustained deviation of the eyes or eye blinking. From
oral, it can manifested as swallowing movement, tongue thrust, lip smacking or chewing
movement. From limb, we can found bicycling of legs, boxing or swimming movement of the
arms or other stereotypic limb movement. From autonomic system, we can found alteration in
blood pressure and/or heart rate, excessive salivation, pupillary dilatation and central apnea
associated with tachycardia. Apnea is a rare manifestation of neonatal seizures, but it is more
common in term infant and usually associated with eye signs.
At the first suspicion of neonatal seizure, the immediate focus should be the exclusion of
rapidly correctable and potentially injurious processes, including hypoglycemia, hypocalcemia,
and hypomagnesemia, among others. More over, the doctor must do septic screen and EEG if he
57
suspect neonatal seizure. In this patient, we check CBC and electrolyte. After that, we also
check septic screen and EEG in this patient.
In this patient, we also found that she has mesocardia. From Kabanjahe Hospital, the doctor
diagnosed her with dextrocardia. We can see it from chest x-ray. So, when she was admitted to
Haji Adam Malik General Hospital, the doctor diagnosed it with dextrocardia at first, but
diagnose changed with mesocardia when echocardiography was performed at May 7th 2013.
In this patient, we also found that she was a postterm baby because her birth was more than
2 weeks later from prediction. After that, the baby’s data was plotted in the graph so that she
was diagnosed postterm neonates-appropriate for gestational age.
Neonatal sepsis is a clinical syndrome characterized by signs and symptoms of infection
with or without accompanying bacteremia in the first month of life. In this patient, we found she
was 8 days old. After that, neonates with sepsis may present with one or more of the following
symptoms and signs, that is hypothermia or fever, lethargy, poor cry, refusal to suck, poor
perfusion, prolonged capillary refill time, hypotonia, absent neonatal reflexes,
brady/tachycardia, respiratory distress, apnea and gasping respiration, hypo/hyperglycemia, and
metabolic acidosis.in this patient, she was found no movement respond since was born.
In theory, neonatal seizure was also one of the clinical feature of neonatal sepsis besides
gastrointerstinal, cardiac, hepatic, renal, hematological, and skin problem. We can found Central
Nervous System (CNS) problem in this patient.
4.2. Summary
This paper reports a case of a 8 days old female baby diagnosed with Postterm neonates-
appropriate for gestational age, unproven sepsis, mesocardia, and neonatal seizure ec
DD(HIE/Intracranial hemorrhage). A comprehensive workup had been done to confirm the
diagnosis. Nevertheless, treatment include antibiotic, anticonvulsant, ad rehydration have been
given to this patient. This patient is in this hospital until now.
58
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