Difficult cases - Case scenarios
Under Category :  Case scenarios
Posted By :  Dr.  CV Phadnis
Posted On : 8/12/2014 7:54 AM
Recurrent pneumonia in a neonate ?
Salient Features
1. Operated case of Tracheo-esophageal fistula
2. Right vocal cord palsy with restricted movements Left vocal cord
3. Acute life threatening episodes {ALTEs}
4. Excessive respiratory secretions and recurrent, migratory pneumonia

The baby is 57 days old
This female baby was born premature at 34 weeks GA by LSCS in view of PROM and the Birth wt was 1.9 kg.
X ray CONFIRMATION : RT coiled in upper esophagus
She was nursed in prone postion and prepared for surgery.{ Color Doppler of heart showed ASD 4 mm and mild PAH. }
She was operated for TOF on day 3 of life. There was a blind upper end of esophagus and there was a fistula with lower end of esophagus. Fistula was closed and esophageal anastomosis was achieved through Right thoracotomy.
The baby was put on ventilator postoperatively. He developed jaundice on Day 4 and was put on phototherapy. On day 5, the baby was noted to have edema, total proteins were 3.8 and S. alb was 2.1, s. creat was 1.2, and baby was given IV albumin and TPN was withheld. The baby improved and was extubated on day 8 of life.
Baby was noted to have copious oral secretions post operatively
.A barium study on Day 10 showed passage of dye to stomach.
On Day 11, he was noted to have CRP of 26 and antibiotics were changed to Piperacillin-tazobactam, Amikacin and Linezolid.
On Day 12, blood culture showed Yeast and hence, fluconazole was added
On day 13, ICD was removed and the baby was stable off O2 and tolerating RT feeds.


On Day 17, 2 episodes of duskiness and deaturation were noted.
He improved with tactile stimulation and was stable.
Stitches taken for thoracotomy were removed on Day 22.
Again, baby was noted to have excessive oral secretions. He was given chest physiotherapy and nebulization was continued.
On day 24, blood culture showed no growth.
She was discharged on day 25 of life.
On day 30, he was brought to the hospital with cyanosis and respiratory distress.
On ABG, pH was 6.9 and pCO2 was 77. He was started on nasal 02, nebulization and chest physiotherapy. He improved in few hours and pH was 7.38, pC02 was 50, and p02 was 83.
On Day 33, he was off oxygen and tolerating full feeds through RT.
On Day 37, he had mild respiratory distress and on 02. Barium study was esophagus was again normal. Also, on day 40 milk scan was normal. Weight had increased to 2.06kg.
On day 42, he was given packed RBCs in view on anemia.{ Hb 9 }
In view of severe stridor , direct laryngoscopy was done on day 44 which showed Right Vocal cord palsy with restricted movement of Left Vocal cord and Tracheo malacia.
On day 45, he had 2 siezures – brief, tonic posturing} and required mechanical ventilation .
Anticonvulsants were added { phenobarbitone, leviracetam}
X ray showed Bilateral lung shadows suggestive of severe pneumonia.
On day 46, USG brain showed mild cerebral edema. ABG showed pH 7.6, pC02 of 26 and p02 of 90.
In view of severe pneumonia and high CRP, Antibiotics were changed to Meropenem, Linezolid and Fluconazole
On day 54, he was extubated and was on O2 by hood and taking feeds through RT
 
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Please give your opinion regarding further investigations and management
Dr. CV Phadnis says,
8/12/2014 7:55:30 AM



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