Thursday, October 27, 2016

Nine interesting cases in Neonates


1. Sepsis presenting with Diabetic ketoacidosis like feature in Preterm neonate

A thriving preterm neonate had new onset sepsis with off color skin and poor feed tolerance. A work up for sepsis was sent and antibiotics were upgraded to 2nd line agents. Inotrope was added for tachycardia with poor perfusion. By evening, there was polyuria with >8ml/kg/hr of urine. We checked our list for any drugs and checked RBS- it was high, so GIR was decreased. By night, baby developed acidotic breathing with severe metabolic acidosis with high blood sugar and urine sugar + ketone +. Fluid corrections were started, and was managed with Infusion of Insulin. Over next 12-24 hours the blood sugar came down to < 150mg/dl. Insulin was stopped and there were no further episodes of hyperglycemia. HbA1c was normal. Baby did well with normal Head scans.
The most interesting thing was the Blood sugar in this baby reached upto 1500mg/dl with ABG ph- 6.9 and HCO3 upto 4meQ/L. 

2. Infective endocarditis in a preterm newborn:
A baby who was ventilated for poor respiratory effort at birth was extubated on day 4 but started developing features of Congestive cardiac failure in late 2nd week. Baby had murmur since Day 2 but we noticed changing nature of murmur and deteriorating cardiac functions. Baby was started on diuretics and also needed Digitalization. Baby remained CPAP dependent. ECHO was requested. Echo located vegetation in RVOT. The baby also had repeated anemia. In background of all these, we started the therapy for IE. Baby remained 50 days in hospital and was discharged with good feeding and weight gain. Adequate control of failure and will follow up soon for repeat ECHO.

3. IUGR baby with recurrent hypoglycemia : Congenital adrenal hypoplasia.
A male baby was transferred in for lethargy and low blood sugar. Despite all management and adequate control of sepsis, it was difficult to wean the baby from IV drip. In background of hyponatremia, hypoglycemia and dark stained genitalia, 21 OHP level was sent which came high and significant. As sample was sent at time of illness, a repeat sample was sent that confirmed CAH. Baby was started on steroid and weaned off IV. Baby was sent for Endocrine consult for optimal care.


4. Down Syndrome with Upper GI obstruction
In view of bilious vomiting and double bubble appearance on Xray, a preliminary diagnosis of Duodenal atresia was made. Baby was operated and on laparotomy has Annular pancreas. A duodenoduodenostomy was done.


5. Three cases of  severe Meconium aspiration with PPHN : Sildenafil magic
For a resource limited condition like ours where NO is a dream, so is HFV, we administered sildenafil. The baby's Oxygenation index decreased over next 12-24 hours and were quickly weaned off ventilators in 2-3 days. A renewed lives from lost hope. One thing that clinicians have to beware is, it can cause refractory hypotension and should be used with caution. It should be avoided in cases with hypotension.

6.  Recurrent SVT in neonate:
It was the first time, we had to use Adenosine in neonate. This was case in India during my course.

7. Corpus callosum Agenesis, ambigious genitalia with refractory seizure:
Baby had atypical genitalia. USG revealed Lissencephaly with corpus callosum agenesis. Baby developed refractory seizure and was difficult to control with 3 antiepileptics so was kept on midazolam infusion. Baby ultimately expired. This was also case seen in India.
Diagnosis was X-linked lissencephaly with absent corpus callosum and ambiguous genitalia (XLAG)

8. Congenital Diaphragmatic hernia to CCHD to Holoprosencephaly:
 A newborn was referred in suspicion of CDH. Baby was cyanosed at birth. On examination, the findings were inconsistent with diagnosis. Chest Xray ordered showed good delineation of diaphragm on both sides. A suspicion of Congenital heart disease was made. Examination showed a huge posterior and anterior frontanels with diasthesis of suture. Baby had mid-facial hypoplasia with depressed nasal bridge.  USG cranium was ordered as such that revealed, Holoprosencephaly. MRI was planned.

9. 1st TEF repair:
EA/TEF was first time repaired in our teaching hospital with success. Baby was taken on academic bed and all procedures was done free of charge. The baby has undergone esophageal dilatation few times and is thriving well. With no other organ involvement, we expect the baby will have near normal outcome. This was an endeavor of Pediatric surgery team Neonatology team, Pediatrics team and Ped Gastroenterologist. None of the less the anesthesia team.




These are some of interesting mention-able cases in last one year. Hoping to see more challenging cases in coming future.

Credits:
Pediatrics and Neonatology Team, NMCTH
Pediatric Surgery and Anesthesia team, NMCTH
Ped Gastro- Dr S. Rimal
Residents, medical officers and NICU staffs
NICU Unit, Sir Gangaram Hospital
Dr Manish Sh , Gangalal Hospital

Thursday, October 6, 2016

New Ballard Score : How to use it correctly


Assessment of gestational age can be made postnatally by either Dubowitz Score or New Ballard Scoring system. In sick infants, examination of Anterior lens canpsule vascularity with a +20D lens can be useful in assessing gestation and it needs to be carried out within 24 hours of birth.

Dr Jeanne L Ballard developed a scoring system based on neurological maturity and physical maturity to assess gestational age of babies. We are all well aware of the charts and scoring system but still many of us are not able to score appropriately and assign gestation age accurately.

Here is the chart-



You can use online calculator as well
Download New ballard score here

The video below demonstrates the procedure of assessment.




When is the appropriate time to perform New Ballard score?
Performed between 30 minutes to 96 hours, ideally within 24 hours. However, studies have debated its validity up to 7 days.
For preterm babies < 26 weeks, it must be done in first 24 hours because on second day babies may suffer from consequences of prematurity.

In such a case, you have two options: Perform the remainder of the neuromuscular criteria, then assign a similar score to the popliteal angle and heel to ear. Wait 24 to 48 hours or until flexor tone has returned to the hamstrings and gluteus muscles, and repeat the assessment For breech deliveries, there may be flexor fatigue in 1st 24 hours so, NBS is performed after 24-48 hours to avoid lower score for lowerlimbs.


Assigning score and gesatational age
For scores between numbers on the grid, we interpolate as follows:
25 = 34 weeks
26 = 34 weeks
27 = 34 weeks
28 = 35 weeks
29 = 35 weeks
30 = 36 weeks

Record only completed weeks of gestation and not partial weeks.
If weeks by exam fall within 2 weeks of KNOWN maternal dates, preferably confirmed by early ultrasound, then the maternal dates are more likely correct.
If weeks by exam are greater than 2 weeks outside of maternal dates in either direction, then the clinical gestational assessment is more likely correct.

References:
New Ballard Score, expanded to include extremely premature infants. Ballard JL et Al.
http://www.ballardscore.com/
Essential Neonatology- Mathur
Validity of New Ballard Score until 7th day of postnatal life in moderately preterm neonates.
Sasidharan K et Al



Thursday, August 18, 2016

Urinary Incontinence or Leaking of Urine

Involuntary loss of urine, continuous dribbling, inability to properly hold urine all account in symptoms of Urinary incontinence. It leads to a personal misery, a health and a social nuisance and is a matter of loss of productivity for an otherwise healthy individual.
Before knowing about the Urinary Incontinence, we need to know a little about Anatomy i.e structure of Urinary System.
As per American Journal of Medicine, 2006, almost half to 4/5th elderly in long term facilities suffered from urinary incontinence. The problem was more often seen in females than in males along all ages. . The US Department of Health and Human Services data estimates that approximately 13 million Americans suffer from urinary incontinence.In the UK, an estimated least 3 million people - 5% of the total population - suffer from urinary incontinence.  In India, a questionnaire-based survey of 2,000 women aged 30-50 in Chennai found a prevalence of about 40 per cent. (Study by GAURI ). Therefore, urinary incontinence is overall a big health issue among women and elderly population. This incontinence is different from enuresis that occurs in children.
                                             
Types of urinary incontinence

Stress Incontinence: When there is an increase in abdominal pressure eg. Sneezing, coughing, laughing and bearing weight, there is leakage of urine.

Urge Incontinence: Incontinence occurring with sudden urge to pass urine.

Mixed: A combination of stress and urge incontinence.

Functional: Neuro-urologic and lower urinary tract dysfunction leading to leakage of urine. (Spinal injury, UTI. Post surgical etc)


Any of the symptoms should always be confirmed by consulting a doctor, so that a hidden pathology is not missed. 



Management
For a successfully managed case of UI, a management plan should be tailored as per pathology, age and cause of incontinence. Role of health professional in counseling and information dissemination is vital.
Some of the General management approaches are:
Pelvic floor physiotherapy, anti-incontinence devices and sometimes surgery are indicated for Stress Incontinence. Urge incontinence requires dietary and behavioral modification, pelvic-floor exercises, and/or medications and newer surgical intervention. Overflow incontinence is treated with bladder catheterization or urinary diversion. Functional incontinence needs the treatment of the underlying cause.

Absorbent products may be used temporarily until the patient undergoes a definite treatment. Adult Pant Style diapers.
Adult diapers are of great value in caring of patient with incontinence.

LIFREE adult diapers are specialized for the care of such problem.

Lifree absorbent Pants are-
1.       With Underwear like elastic. Easy to wear and remove for elderly as well.
2.       Light and comfortable with extra stretch ability
3.       A good adsorption system that can prevent leakage of urine as well.
4.       Soft leg passage with flexible opening for legs.
 The product is available for those who are capable of walking to toilet independently- Pant type
With time and experience, researches were carried out to improve the patient or consumer comfort and better design and materials are now used for Adult adsorbent pants. Now a days, the products have higher absorption, less discomfort, no soiling problems that occur accidentally and are available over the counter. A brand, Lifree has been making its mark sales in India.


For more details visit: Lifree ‘Japan’s number 1 brand*’: http://www.lifree.co.in/index.html

Thursday, August 4, 2016

How to check an Error in ABG ? ABG analysis



Sometimes, clinicians might find ABG result not matching with the patient condition. These results might arise from technical errors in machine and there are certain points which can be used to check the error.

How to Check whether ABG result is Right or has Error?






1. Check patient and ABG correlation

2. Check Lab values: If TCO2- HCO3 > 4meq/L , likely technical error.

3. For pH 7.3 to 7.5, actual bicarb should be

X= 24X PaCO2/HCO3

Y= 80- V

Y should be around last 2 digits after decimal of pH.

V= 30

4. PaO2 –pCo2 relationship: paO2 + PaCO2 should never exceed > 150 mmHg( if not under oxygen.)

5. PaO2-FiO2 relationship.
Also


And



If you have any comments, please leave it below.

Wednesday, July 20, 2016

Common mistakes in Per Abdominal examination

1. Forgetting to Expose abdomen adequately:
Before examination, patient should ideally be exposed from nipples to mid thigh. Failure to do so may lead to missing findings during examination eg. Hernia



2. Abdominal symmetry and movement: Should be examined tangentially and from leg end. Comment should be made on movement of all quadrants with respiration.

3. Forgetting to relax abdomen before palpation:
Flex the legs at knees and arms should be by side of body. Head should be rested on a pillow. Only after abdomen is in relaxed position palpation should be proceeded.

4. Missing points on palpation:
a. Remember to ask for pain in any site before palpating. The part with pain should be skipped and palpated at the end.
b. Look for rigidity and guarding besides tenderness.
c. Tenderness should be assessed by looking at facial expression +/- guarding
d. Remember to palpate urinary bladder
e. Hernial orifices should be palpated and is commonly missed point.
f. Make the patient sit and check for renal angle fullness and tenderness.


Rarely grading can be asked.


5. Remember- Shifting dullness is done in percussion and fluid thrill is done in palpation, in a patient with abdominal distension.

6. Auscultation- Look for Renal bruit, Hepatic bruit etc in indicated cases. Bowel sound  should be listened to. When bowel sounds are not present, one should listen for a full 3 minutes before determining that bowel sounds are, in fact, absent.



Recommended reading
https://meded.ucsd.edu/clinicalmed/abdomen.htm
http://www.ncbi.nlm.nih.gov/books/NBK420/