Case discussion: bloody stools and abdominal distension

[oldbearprofessor]

The differential diagnosis of bloody stools in a 33-35 week infant is among the most difficult ones we have in neonatology. There are at least 3-4 major possibilities and not uncommonly, interns are at the front line of trying to figure this out. So, lets try a case - remember, more senior members to let the med students and interns have a crack at this.

So, you are a general pediatrician covering a community hospital when you are called at 0200 about a 4 day old infant that you are cross-covering for. You otherwise don't know anything about the patient. The nursery that is calling you is a "lower" level 2 nursery - will take care of babies at 32 weeks or above, can do short term IVs and n/g tubes, no cpap and no vents.

The call nurse says "Baby Bear is a 4 day old, now 1900 gram former 33 weeker who is getting n/g feeds of 40 cc q 3 hours and just had a big bloody stool. His vital signs are HR 170, RR - 40, T- 98.8 and BP 90/60."

you ask about abdominal distension and color and get fairly vague "slightly distended, color looks okay, we're putting a pulse ox on now" response.

What do you ask now and what do you recommend they do during the 30 minutes it will take you to get dressed and come see the baby? Note that this is a very small hospital and the only 24/7 doc is an EM moonlighting resident and X-rays, labs don't exactly happen at 2 AM too fast.

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[Stitch]

bump
Sounds like a good case, and not unlike some of my current moon lighting.
Since no one else is jumping in, I just wanted to ask a few questions.
Any pregnancy complications or problems or exposures? Any reason for the premature delivery (concern for chorio or abruption)? What were the perinatal complications and was any resuscitation necessary immediately after birth? Has the infant been on antibiotics recently?

There are a number of things that concern me with the information given, but I'll hold off for now and hope others jump in.

 

[oldbearprofessor]

bump
Sounds like a good case, and not unlike some of my current moon lighting.
Since no one else is jumping in, I just wanted to ask a few questions.
Any pregnancy complications or problems or exposures? Any reason for the premature delivery (concern for chorio or abruption)? What were the perinatal complications and was any resuscitation necessary immediately after birth? Has the infant been on antibiotics recently?

There are a number of things that concern me with the information given, but I'll hold off for now and hope others jump in.

Yeah, take a chance guys...you wanted cases, you didn't say they had to be EASY ones.

Usual history - preterm labor, otherwise unremarkable, ROM with delivery. Got a 48 hour r/o sepsis with antibiotics stopped after 48 hours. Apgars 8/9.

 

[Chuck's Right Foot]

Can't wait till I learn medical-ese to understand the abbreviations! Hope to see some good discussion!

 

[Dimoak]

When was the ng tube placed, and was there any x-ray to confirm it didn't coil? (sorry for the weak question, but I'm trying to get started heh)

 

[oldbearprofessor]

When was the ng tube placed, and was there any x-ray to confirm it didn't coil? (sorry for the weak question, but I'm trying to get started heh)

Baby has been on n/g feeds since 12 hours of age. If it was coiled (due to TEF), it would have been picked up before now. Good idea though.

 

[stiffany]

Okay, I'll take a stab as an about to be MS3: Any indications for infection (NEC, especially with the empiric antibiotics)? What was the mom's status (Group B strep, that kind of thing)? Any delays in passing meconium? Has the baby been fussier than "normal" for your average 33 week-er or more somnolent? Is the abdomen rigid or soft? Has the baby been normally feeding since then? Any obvious reason for the prematurity?

I really want that abdominal x-ray to check for bowel loops or air bubbles!

 

[oldbearprofessor]

Okay, I'll take a stab as an about to be MS3: Any indications for infection (NEC, especially with the empiric antibiotics)? What was the mom's status (Group B strep, that kind of thing)? Any delays in passing meconium? Has the baby been fussier than "normal" for your average 33 week-er or more somnolent? Is the abdomen rigid or soft? Has the baby been normally feeding since then? Any obvious reason for the prematurity?

I really want that abdominal x-ray to check for bowel loops or air bubbles!

So, remember that the scenerio is that you're on the phone with the bedside nurse and you have to decide - do I want her to spend 20 minutes going through the chart and trying to get me this type of information (Which will be hard to find), or do I want to make a very quick mental differential, tell them some things to do and then start to head in to the hospital. This is a very real conundrum. The more you ask, the more you aren't THERE.

So, you ask briefly about the belly and get "it seems big and full". You then ask for them to start an IV, get an abdominal X-ray, draw a CBC and make the baby NPR.

You start to head into the hospital. These things will NOT be completed before you get there, except maybe the IV.

What is your differential? not everything, just the things that you are most concerned about? What IV fluids did you ask them to hang when you made the baby NPO and at what rate?

 

[generic]

OK, here goes nothing:

How about asking to hang D5 1/2 Normal Saline at 8cc/hr in the bag (I'm trying for maintenance since I made baby NPO, and doesn't seem hypovolemic shocky by vitals--may be starting to get volume depleted but only 1 bowel mvmt so far...)

DDx:

NEC
C. diff colitis
other dysentary (any sick contacts?)
Meckel's Diverticulum
Intussuception
Protein allergy/intolerance

 

[stiffany]

So, remember that the scenerio is that you're on the phone with the bedside nurse and you have to decide - do I want her to spend 20 minutes going through the chart and trying to get me this type of information (Which will be hard to find), or do I want to make a very quick mental differential, tell them some things to do and then start to head in to the hospital. This is a very real conundrum. The more you ask, the more you aren't THERE.

So, you ask briefly about the belly and get "it seems big and full". You then ask for them to start an IV, get an abdominal X-ray, draw a CBC and make the baby NPR.

You start to head into the hospital. These things will NOT be completed before you get there, except maybe the IV.

What is your differential? not everything, just the things that you are most concerned about? What IV fluids did you ask them to hang when you made the baby NPO and at what rate?

I'm really worried about NEC in this premature baby especially given the fullness of the abdomen, the blood, and the antibiotic use. I'm also worried about obstruction (intusseception, volvulus) or an infectious etiology such as Campylobacter. Meckel's diverticulum causing obstruction and/or inflammation. I also wonder about drugs used in the first few days of this newborn's life which might cause bleeds.

I have no idea about the rate, but would one want to use 0.9 saline to replace the volume potentially being lost from a possible bleed?

I assume a CBC was requested to to check the hemoglobin (for blood loss) and the WBC for possible infection. Any other reasons based on the scenario?

 

[smq123]

I assume a CBC was requested to to check the hemoglobin (for blood loss) and the WBC for possible infection. Any other reasons based on the scenario?

A lot of times people will get a starting CBC so that they can follow what changes occur with any subsequent CBCs.

In a lot of cases the actual lab values are not as important as trends. A WBC that is 10 is not as big of a deal if it was 9 yesterday; it could potentially be a much bigger deal if it was 5 yesterday.

 

[oldbearprofessor]

OK, here goes nothing:

How about asking to hang D5 1/2 Normal Saline at 8cc/hr in the bag (I'm trying for maintenance since I made baby NPO, and doesn't seem hypovolemic shocky by vitals--may be starting to get volume depleted but only 1 bowel mvmt so far...)

DDx:

NEC
C. diff colitis
other dysentary (any sick contacts?)
Meckel's Diverticulum
Intussuception
Protein allergy/intolerance

Reasonable differential (and Stiffany's too)

Does NEC occur at 34 weeks Post-menstrual age?

With regard to the IV fluids, D5 at 8 cc/hr in a 1900 g infant would provide what GIR? What is the usual minimum GIR to provide IV to a small infant? Why 1/2 NS? what about potassium?

 

[smq123]

Does NEC occur at 34 weeks Post-menstrual age?

I don't know enough to say "never" - but most common in 30-33 GA range?

 

[smq123]

So, you ask briefly about the belly and get "it seems big and full". You then ask for them to start an IV, get an abdominal X-ray, draw a CBC and make the baby NPR.

There's something probably really obvious that I'm not seeing - but why just a CBC, and not a BMP along with it?

 

[J-Rad]

...start an IV, get an abdominal X-ray, draw a CBC and make the baby NPR.

I agree with NPR...no babies like stuff put up their butt. Alternatively I hear 33 weekers love Prairie Home Companion

I'll throw out that there is a test that can give you some answers (not the diagnosis) that you (some of the above posters) want in less than a couple of minutes after you get your sample. It also may influence how worried you are.

 

[oldbearprofessor]

There's something probably really obvious that I'm not seeing - but why just a CBC, and not a BMP along with it?

Depending on the hospital, you may get uninterpretable numbers from the heel stick. Needs to be done, but probably won't point you towards the diagnosis too much in this case, so, in the middle of the night in a community hospital, it wouldn't be your first priority. Not unreasonable to do with the CBC however.

 

[oldbearprofessor]

I agree with NPR...no babies like stuff put up their butt. Alternatively I hear 33 weekers love Prairie Home Companion
.

Just don't play "it's a small world..."

I'm post-call, make that NPO, not NPR

 

[Dimoak]

Reasonable differential (and Stiffany's too)

Does NEC occur at 34 weeks Post-menstrual age?

With regard to the IV fluids, D5 at 8 cc/hr in a 1900 g infant would provide what GIR? What is the usual minimum GIR to provide IV to a small infant? Why 1/2 NS? what about potassium?

Do we have the pulse ox values yet? Does the baby have ischemic risk factors? Hypercythemia? That AbXR would be nice.

 

[Stitch]

Reasonable differential (and Stiffany's too)

Does NEC occur at 34 weeks Post-menstrual age?

With regard to the IV fluids, D5 at 8 cc/hr in a 1900 g infant would provide what GIR? What is the usual minimum GIR to provide IV to a small infant? Why 1/2 NS? what about potassium?

I'm glad people are jumping in!

From my experience NEC can occur to almost anyone, it's just more rare the older the gestational age. I agree with wanting the abdominal films and CBC.

Is anyone else concerned by the initial info given? The kid is only 4 days old, 2 days past his antibiotic rule out and he's feeding at nearly 170 mL/kg/day. That seems a bit fast and a bit much. I'm usually a little more conservative with fluid and feeds. Plus he's a little tachycardic.

For those who need the GIR formula, here it is (hint5 won't be enough)
GIR (mg/kg/min) = Volume (mL/kg/d) x Glucose concentration (as a decimal) ÷ 1.44

Or

GIR (mg/kg/min) = IV rate (mL/hr) x Dextrose concentration (g/dL) x 0.167/Weight (kg)

 

[oldbearprofessor]

For those who need the GIR formula, here it is (hint5 won't be enough)
GIR (mg/kg/min) = Volume (mL/kg/d) x Glucose concentration (as a decimal) ÷ 1.44

My formula of choice. So, his GIR is basically 100*0.05/1.44 = about 3.5 mg/kg/min.

Minimum in this circumstance would be about 5-6 mg/kg/min.

Therefore, always hang D10 on newborns in the first month of life UNLESS they are obviously severely hyperglycemic (rare in this type of circumstance) OR < 1000 g.

Feeds at 168 mL/kg/d of a 20 kcal/oz formula or breast milk would provide < 120 kcal/kg/d so that's why they built up so fast. I didn't say I did that, just that it wasn't that uncommon. It wouldn't matter much if they'd only advanced to 35 ml/feed or about 145 mL/kg/d.

This baby was receiving a mix of mom's milk when available and a 22 kcal/oz transitional formula. He had been started on Day 1 at 80 ml/kg/d and advanced over 72 hours to the 40 ml/feed volume.

More later.

 

[oldbearprofessor]

As you are driving in, about 25 minutes after the first call and about 10 minutes before you get to the hospital and to the nursery, you get a STAT page.

You respond and are told

"The baby just had another bloody stool and now his abdomen is very distended. He's breathing okay, but the perfusion doesn't look good. X-ray just got here and the CBC has been drawn."

Your further advice at this moment would include? Remember, you'll be there in 10 minutes, but what are some things you'd tell them now recognizing that these things will be in progress as you arrive. Do not say "call for transport...."

 

[Depakote]

As you are driving in, about 25 minutes after the first call and about 10 minutes before you get to the hospital and to the nursery, you get a STAT page.

You respond and are told

"The baby just had another bloody stool and now his abdomen is very distended. He's breathing okay, but the perfusion doesn't look good. X-ray just got here and the CBC has been drawn."

Your further advice at this moment would include? Remember, you'll be there in 10 minutes, but what are some things you'd tell them now recognizing that these things will be in progress as you arrive. Do not say "call for transport...."

No experience on peds, but thinking out loud here...

If breathing is good but perfusion isn't, would it be a good idea to start oxygen?

What's the BP? (what's normal in a preemie) I think I saw earlier that we're giving normal saline. I know we want that to maintain pressure, is that sufficient?

 

[Dimoak]

As you are driving in, about 25 minutes after the first call and about 10 minutes before you get to the hospital and to the nursery, you get a STAT page.

You respond and are told

"The baby just had another bloody stool and now his abdomen is very distended. He's breathing okay, but the perfusion doesn't look good. X-ray just got here and the CBC has been drawn."

Your further advice at this moment would include? Remember, you'll be there in 10 minutes, but what are some things you'd tell them now recognizing that these things will be in progress as you arrive. Do not say "call for transport...."

Is there somewhere there who can give reliable impressions on gas in the abdomen?

 

[stiffany]

Okay, newb question: What's a GIR formula (something infusion rate maybe)? I tried googling it and came up with this green monster looking thing.

I'm especially worried about the poor perfusion and am beginning to think about the possibility of shock. In addition to the oxygen as Depakote suggested, do we want to prepare to mechanically ventilate the kid in the event our pulse ox starts making things look even worse? Should we also ensure proper warming so s/he doesn't have to work as hard to achieve homeostasis in the interim? What's the CO2 and pH (Can we get an ABG)? What about a DIC panel? Empiric antibiotics? Should we go ahead and type and cross-match so if we need to provide blood we can do so?

 

[oldbearprofessor]

What's a GIR formula (something infusion rate maybe)?

Glucose infusion rate.

 

[smq123]

I'm especially worried about the poor perfusion and am beginning to think about the possibility of shock. In addition to the oxygen as Depakote suggested, do we want to prepare to mechanically ventilate the kid in the event our pulse ox starts making things look even worse? Should we also ensure proper warming so s/he doesn't have to work as hard to achieve homeostasis in the interim? What's the CO2 and pH (Can we get an ABG)? What about a DIC panel? Empiric antibiotics? Should we go ahead and type and cross-match so if we need to provide blood we can do so?

Wait, wait, wait! Hold up - I still have some questions about things from a few posts back!

Why 1/2 NS? what about potassium?

I've started to realize that one of the things I've rarely been able to get a very clear answer on is choosing between NS and LR, or NS with potassium added. I read your post where you (very nicely) laid out the need for D10 over D5 - but in this scenario, is there anything particularly wrong with ordering D10 - NS? Or would you rather give the baby some LR instead?

"The baby just had another bloody stool and now his abdomen is very distended. He's breathing okay, but the perfusion doesn't look good. X-ray just got here and the CBC has been drawn."

Your further advice at this moment would include? Remember, you'll be there in 10 minutes, but what are some things you'd tell them now recognizing that these things will be in progress as you arrive.

My first instinct would be to start supplemental O2 by nasal cannula, to try and bring his O2 sats up. Get an ABG.

[By the way - thanks for posting these cases, both this one and the one you posted a few weeks ago. I'm not going into peds, but I will be spending some "quality time" in the PICU/NICU setting soon...and while these cases are scaring me, it's a good-scary. Better to be scared here than when I'm the one in the call room....]

 

[oldbearprofessor]

I've started to realize that one of the things I've rarely been able to get a very clear answer on is choosing between NS and LR, or NS with potassium added. I read your post where you (very nicely) laid out the need for D10 over D5 - but in this scenario, is there anything particularly wrong with ordering D10 - NS? Or would you rather give the baby some LR instead?

Heck, we don't even know what's in LR! We tend to be very specific in giving what we need. If we need a volume bolus, we'll give 10 mL/kg of NS, if we are giving maintenance we'll give 100-120 mL/kg of D10 with the amount of Na and K+ we need for maintenance (usually 2-3 mEq/100 mL). Same thing for adding calcium. So, to hang D10 NS as maintenance would be too much saline as maintenance. We'll save it for boluses.

 

[oldbearprofessor]

In addition to the oxygen as Depakote suggested, do we want to prepare to mechanically ventilate the kid in the event our pulse ox starts making things look even worse? What's the CO2 and pH (Can we get an ABG)? What about a DIC panel? Empiric antibiotics? Should we go ahead and type and cross-match so if we need to provide blood we can do so?

So, in a test situation, these are great ideas, but in the real world I live in and deal with, as do many others, you have to figure out the pros and cons of each of these.

For example, if you are not there, calling in and telling them to intubate means what? Who is going to do it? If you have someone not well experienced in intubating and ventilating preterm infants (like a pediatrician or family doc who hasn't done this in a long time if ever? or even an EM doc who hasn't intubated and ventilated small babies), the risk of disaster (pneumothorax, etc) may exceed the benefit to putting the tube in. Do they even have the right ventilator? What do they do about sedation? etc.

Getting an ABG isn't so easy either. Again, who is going to do it. If you haven't drawn an ABG before from a shocky preterm infant I can assure you it isn't the easiest procedure. Even if you succeed you may just have blown one of two radial arteries that could be needed for a radial art line. Not so cool. Get a capillary gas? Okay, not easy to get a good one in the middle of the night in a community hospital.

Empiric antibiotics? Type and cross? These again can be 30-90 minute procedures and along with your DIC panel, the type and cross will need a venipuncture and 3-5 ml of blood. Good luck with that. Where are you going to give the gentamicin - a 30 minute infusion in a shocky baby with one IV site who is getting a glucose infusion.

So, you have good ideas here, but everything has to be balanced. Even in a big NICU, you have to figure out priorities, what to use what line for, etc. We just can't intubate, start 3 large bore IV's and an art line in a premie!

 

[oldbearprofessor]

You give the following instructions on the phone, remembering that you are about 10 minutes away from the hospital.

In your mind, your presumptive diagnosis is some form of abdominal catastrophe with or without sepsis. Whether it is a ruptured intestine, NEC or a septic ileus is unclear and not that crucial for the next few minutes.

you ask them to:

1. Place a large n/g tube to suction (replogle to LIS)
2. Push 10 ml/kg of NS over 10 minutes
3. Draw a stat capillary blood gas
4. Start 2 L nasal cannula and prepare for intubation (stat page RT to set up a ventilator).
5. Order a dose of antibiotics.
6. Start a second peripheral IV if possible for the antibiotics.
7. Have someone call mom if she is already home and advise her to come to the hospital urgently or go to her room if she's still in house. (tough call here, some might prefer to wait until they get to the hospital to call mom, depends on the situation).
8. Type and Cross and have 20 mL/kg PRBC to the bedside ASAP

As you walk in the NICU, they hand you the x-ray....to be continued tomorrow....

Questions: What antibiotics would you recommend? In what order to be given? Time and IV access are crucial

What do you expect to find on the gas. What pH, PCO2 would lead you to intubate?

What size ETT do you plan to use to intubate?

 

[J-Rad]

Please don't give me the Ole' bear beat down for the (admittedly) neophyte quibbling with the respected Neo, but one quibble I have with the above is the NS bolus over 10 minutes. As a 1900 gm former 33 weeker this baby isn't in the terribly high risk for IVH that might be exacerbated by rapid infusion of fluids. I think a bolus for poor perfusion (and ominous clinical scenario) should be just that-a bolus. I.E. push it in a syringe as fast as the needle will take it.

SMQ123: the issue of fluids is an interesting one. In the neonatal period (say 1st 30 days of life) the kidneys are pretty dumb and may not tolerate higher sodium loads. In older children (not the patient in this case) the dogma has been to use 1/4NS, 1/2NS and NS (base) fluids based on age based on estimates of electrolyte "needs". This is based on an article published by Holliday and Segar (also the article from whence everyone doses the MIVF rates 10-4, 10-2, 1-1). The dogma is fairly well entrenched, however, there are those that argue that it isn't good dogma (Moritz being the main proponent). If you read the original article the "evidence" for this approach is fairly underwhelming. So to save myself from thinking a whole lot, when I write the fluid orders, almost every (older) kid goes on D5NS with 20 of KCL (if kidneys working and peeing). LR is used a lot in the OR and not infrequently in the ED. Don't remember seeing it in the NICU and did use it sometimes in the PICU.

 

[Dimoak]

You give the following instructions on the phone, remembering that you are about 10 minutes away from the hospital.

In your mind, your presumptive diagnosis is some form of abdominal catastrophe with or without sepsis. Whether it is a ruptured intestine, NEC or a septic ileus is unclear and not that crucial for the next few minutes.

you ask them to:

1. Place a large n/g tube to suction (replogle to LIS)
2. Push 10 ml/kg of NS over 10 minutes
3. Draw a stat capillary blood gas
4. Start 2 L nasal cannula and prepare for intubation (stat page RT to set up a ventilator).
5. Order a dose of antibiotics.
6. Start a second peripheral IV if possible for the antibiotics.
7. Have someone call mom if she is already home and advise her to come to the hospital urgently or go to her room if she's still in house. (tough call here, some might prefer to wait until they get to the hospital to call mom, depends on the situation).
8. Type and Cross and have 20 mL/kg PRBC to the bedside ASAP

As you walk in the NICU, they hand you the x-ray....to be continued tomorrow....

Questions: What antibiotics would you recommend? In what order to be given? Time and IV access are crucial

What do you expect to find on the gas. What pH, PCO2 would lead you to intubate?

What size ETT do you plan to use to intubate?

Size 3 ETT, 6F SC, Miller 0 blade.

Also, I thought you're not supposed to use NS on neonates (LacRings instead) due to acidosis concerns?

 

[Pepipanda]

What does NS stand for? Normal saline?

Also, what are LR, DIC, and ABG?

 

[Stitch]

Please don't give me the Ole' bear beat down for the (admittedly) neophyte quibbling with the respected Neo, but one quibble I have with the above is the NS bolus over 10 minutes. As a 1900 gm former 33 weeker this baby isn't in the terribly high risk for IVH that might be exacerbated by rapid infusion of fluids. I think a bolus for poor perfusion (and ominous clinical scenario) should be just that-a bolus. I.E. push it in a syringe as fast as the needle will take it.

I agree. What do you say OBP? Also, can we do UVCs in this hospital? I'd seriously consider lines once I got there.

My other question is in getting the cap gas. I've generally found them to be not so helpful because your question of "For what pH, PCO2...etc do you intubate." If anything I'd argue that the pH is perhaps the most useful in a kid with respiratory distress, but I can guarantee this kid is acidotic (likely metabolic) and retaining some amount of CO2. So how do you feel about intubating mainly on a clinical picture then checking a gas once on the ventilator to get a starting point, kind of like we do in severe asthmatics?

Peripanda here's a translation:
NS=normal saline. 0.9% or 154 meq NaCl
LR=lactated ringers. sodium130 mEq, potassium 4 mEq, calcium 3 mEq, chloride 109 mEq and lactate 28 mEq. It's isotonic.
DIC=disseminated intravascular coagulation. Clotting and bleeding at the same time as your clotting factors get all used up. Usually bad.
ABG: arterial blood gas. measures pH, oxygen and carbon dioxide levels along with the base bicarbonate.

 

[oldbearprofessor]

Please don't give me the Ole' bear beat down for the (admittedly) neophyte quibbling with the respected Neo, but one quibble I have with the above is the NS bolus over 10 minutes. As a 1900 gm former 33 weeker this baby isn't in the terribly high risk for IVH that might be exacerbated by rapid infusion of fluids. I think a bolus for poor perfusion (and ominous clinical scenario) should be just that-a bolus. I.E. push it in a syringe as fast as the needle will take it.

I agree. What do you say OBP? Also, can we do UVCs in this hospital? I'd seriously consider lines once I got there.

My other question is in getting the cap gas. I've generally found them to be not so helpful because your question of "For what pH, PCO2...etc do you intubate." If anything I'd argue that the pH is perhaps the most useful in a kid with respiratory distress, but I can guarantee this kid is acidotic (likely metabolic) and retaining some amount of CO2. So how do you feel about intubating mainly on a clinical picture then checking a gas once on the ventilator to get a starting point, kind of like we do in severe asthmatics?

Tough crowd .

I thought I was gonna get grief for pushing in the NS too fast....since most folks learn to do it over 20 minutes, which is great for routine low UOP use, but not shock. In this case, remember that you aren't there yet and few if any bedside nurses will be allowed to "push" anything without a doc or at least NNP present. So, giving the order over 10 minutes will get it started until you get there.

As far as the CBG, for sure a baby like anyone else can be intubated on clinical grounds, but in this population, we usually use apnea as our guide. Since there isn't anyone there to actually do the intubation, ordering a gas is a reasonable thing to suggest. Remember that you haven't seen this baby yet. It could just be CMPA and the baby will be smiling at you as you walk in. Or, it could be more ominous....

As you walk in, they hand you the X-ray, which I will try to post soon and give you the following lab:

pH 7.08, PCO2 - 35, sodium - 135, K+ 5.8, WBC 4,000 with 3 bands and 2 segs and plts 140,000.

No one has told me what antibiotics to order?

 

[generic]

How about good ole

Ampicillin

Gentamicin

Then again, those may be the antibiotics he/she got for 48 hrs previously.

I'm concerned about intestinal flora=gram negatives-->seems like an aminoglycoside would be a good choice. So that might be the one I would prioritize first when they get a 2nd PIV in place.

 

[oldbearprofessor]

First film:

Questions:

1. What is the diagnosis?
2. What is the prognosis?
3. Mom walks in the nursery with dad at that moment and they ask "What is happening to our baby? Will he be okay?" What do you say?
4. Do you intubate?
5. What else do you do now?

I'm going to let responses come up for the rest of the day and return with comments later in the day or in the AM. Let the group talk about this for a while.

 

[Dimoak]

First film:

Questions:

1. What is the diagnosis?
2. What is the prognosis?
3. Mom walks in the nursery with dad at that moment and they ask "What is happening to our baby? Will he be okay?" What do you say?
4. Do you intubate?
5. What else do you do now?

I'm going to let responses come up for the rest of the day and return with comments later in the day or in the AM. Let the group talk about this for a while.

1.) NEC with complete ileal compromise.
2.)
3.) Tell her we're doing the best we can but we will have to "watch and wait".
4.) Probably, although the lab values are a little weird?
5.) Gentamicin 10mg drip, TPN, stat surgical consult.

 

[J-Rad]

In residency the running theme was "what are you going to do when you get to your island?". I.E., when you get to your duty station somewhere in the middle of the ocean-then what?
It was always emphasized that when you got there to know what your capabilities are and know who your freinds are. Also know who might need a little help. Ex.: The pharmacy may have Alprodostil like it's supposed to, but the pharmacist may have not dispensed it in the last five years. Make sure the staff knows how to mix and infuse it.
What if rapid transport isn't available? You're a few hours away from your Level III NICU and pediatric subspecialists and LifeFlight isn't going to fly since it's foggy out (or the C-17 isn't going to get to your island for 8 hours). Who are your friends?

 

[J-Rad]

Vanc (staph was always a concern where I trained), Cefotax or Cefipime, Flagyl.

OBP, can you link to a bigger picture of the belly film. I get the gestalt, but I'd like a better view of some of the details (for academics' sake).

Dimoak: what's weird about the labs?

Any other medications you might want handy?

 

[Depakote]

reposting the image per OBP's request:

 

[J-Rad]

The larger image came out pretty grainy, so I found a pretty nice picture online of what we think this is. Note the "arrow-points-here" signs. Then look at the rest of it too.

http://bms.brown.edu/pedisurg/Brown/IBImages/NEC/Portal_Venous_Gas.html
If you can't see the picture, like I can't.

 

[Dimoak]

Dimoak: what's weird about the labs?

Well the acidosis is there, but I would've expected lower Na and way fewer platelets given the extent of disease. WBC count seemed a little too low as well, although we weren't provided neutrophil data. I suppose I have some reading to do.

 

[J-Rad]

Well the acidosis is there, but I would've expected lower Na and way fewer platelets given the extent of disease. WBC count seemed a little too low as well, although we weren't provided neutrophil data. I suppose I have some reading to do.

Does any of that information make you think you're going to change your initial management? Remember when you get grouped lab results (CBC, Basic Metabolic Panel, etc) you often get information that you may have little use for. Think of what do you actually want to know, and how you 1) got the data 2) what you're going to do with the data and 3) what is the patient doing that may override the data (the clinical exam trumps numbers much of the time).

 

[smq123]

What does NS stand for? Normal saline?

Also, what are LR, DIC, and ABG?

NS = Normal saline (0.9% solution). An extremely commonly used IV fluid.

LR = Lactated Ringers (a.k.a Ringer's Lactate). Another commonly used IV fluid.

DIC = Disseminated Intravascular Coagulation. A disease where clots start to form in the bloodstream, which eats up the platelets and coagulation factors, and leads to excessive bleeding elsewhere.

ABG = Arterial Blood Gas. A test done by removing a sample of arterial blood (MUST BE ARTERIAL! NOT VENOUS!) and sending it to the lab ASAP so that they can calculate the pH of the blood, how much oxygen is in it, how much carbon dioxide is in it, etc. Usually used as a measure of how well the patient is getting oxygen throughout the body.

 

[J-Rad]

ABG = Arterial Blood Gas. A test done by removing a sample of arterial blood (MUST BE ARTERIAL! NOT VENOUS!) and sending it to the lab ASAP so that they can calculate the pH of the blood, how much oxygen is in it, how much carbon dioxide is in it, etc. Usually used as a measure of how well the patient is getting oxygen throughout the body.

Must be arterial for an ABG (from a semantic standpoint), but why must you have an arterial sample? OBP was OK with a CBG. What's your rationale?

 

[smq123]

Must be arterial for an ABG (from a semantic standpoint), but why must you have an arterial sample? OBP was OK with a CBG. What's your rationale?

I was talking more from a definition standpoint, and not this particular case. I actually just saw that post in isolation and forgot that OBP wanted a CBG instead for this particular patient.

Been doing adult medicine too long. I'm still scarred from the fallout after the abnormally dark "ABG" I drew when I was in the ICU....

 

[smq123]

Vanc (staph was always a concern where I trained), Cefotax or Cefipime, Flagyl.

I was also thinking Cefotax + Flagyl....but....

...again, one of those things that I can recognize as a problem, but am still not too sure on what to do about it.

If the baby has one peripheral IV, how do we run them? In what order and how, if a second line can't be placed easily? I can't imagine that if the baby is really toxic you'd worry about starting a central line...

 

[Dimoak]

Does any of that information make you think you're going to change your initial management? Remember when you get grouped lab results (CBC, Basic Metabolic Panel, etc) you often get information that you may have little use for. Think of what do you actually want to know, and how you 1) got the data 2) what you're going to do with the data and 3) what is the patient doing that may override the data (the clinical exam trumps numbers much of the time).

I agree; it was mostly out of an academic interest. I didn't realize WBCs could go either way in neonatal NEC.

 

[J-Rad]

Dimoak, smq123 don't be afraid to throw stuff out. Believe it or not your med student training is relevant here. You might not know the exact answer, but neither does the pediatric resident. Have a little fun with this. OBP's like Yoda and I guess Stitch and I are fresh Jedi Knights. You're like the kids at the temple, but nobody's gonna cut you in half with a light saber . Go for principles, not details (who cares which three antibiotics, the principle is broad spectrum w/ anaerobic coverage. That's what was going through your head-appropriately).
So for you smq, what if your patient was a geezer hanging out on the step down. IV access is minimal and what was there was a pain to get. And he gets a distended abdomen and has a bloody stool. What are the principles of your treatment (the DDx is different, although NEC is known rarely to occur in adults) and plan. And remember you don't work alone.

 

[oldbearprofessor]

The discussion is going great, so I'll keep my comments for now to a minimum.

The WBC often is < 5000 in early neonatal sepsis. At 4 days of age, it can be low, medium or high. But a relatively low ANC count is of concern. Really though, who cares in this patient what the WBC count or diff is? It won't affect yours or anybody's treatment. Similarly, in the first few hours, platelet count can be normal. Watch for it to drop after a short period of time, but it may be normal initially.

As J-Rad says, the actual choice of antibiotics is a bit institution-specific. The key is figuring out what classes and which ones to give first. Keep in mind that although getting a dose of antibiotics is important, volume comes first.

You'll have no real way of getting a central line in this baby acutely. Even if a UVC was feasible, you have an acute massively distended tender abdomen and there's no way to go into that with a UVC. You need to press the nurses to start several peripheral IVs before the inevitable hypotension and need for pressors, etc.

In the real world, you'll spend a lot of time struggling with line management and sequencing of meds and fluids, less time on the philosophy.

But, back to this baby, any comments on the prognosis or what to say to mom other than "we'll see"?