Presentation Utk State Meetng ( DR DAUD)

8/12/2019 Presentation Utk State Meetng ( DR DAUD)

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Nama Ibu dan No. K/P Nama Anak Alamat Tetap KlinikBerhampiranTarikh /Tempat

Kematianibu

MatiDalamPerut

Umur Semasa Mati

SebabKematianDan Lain-

Lain Catitan0 - 6 Hari 7 - 27 hari28 - 1

Tahun

1- 4

tahun

5 - 6

Tahun

MAIZATUL AKMA 821119036081 TG NUR AMALINA BTTG TARMIZI

KG CHENGALLEMPONG

KK BALOK

26/10/13HOSPKOTA

BHARU

6 BULANSEPTICEAMIAWITH BILIARY

ATREASIA

SENARAI KEMATIAN DIDAWAH UMUR 5 TAHUN PKD KUANTANOKT DEC 2013


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SECTION 1:

Patient Details


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1. Name: TENGKU NUR AMALINA BT TG. M.TARMIZI

2. MyKid No.: 130507060586 (5 MONTHS 19 DAYS)

3. Residence: NO.9 KG. PANJANG BANGGU, 16150 KOTA BHARU

4. Ethnicity: MALAY Nationality: MALAYSIAN

5. Gender: FEMALE

6. Date of Birth: 07 TH MAY 2013 @1300


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SECTION 2:Patient Death Details


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7. Date & Time of Death: 26/10/ 2013 @ 1800PM

8. Place of Death: Home Clinic On way to hospital

/ Others, specify: PICU HPSZ II

9. Person Certifying Death:

/ Medical, specify: M O

Non-medical, specify:


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10a. Symptom(s) of current illness leading to death:

/ Not Applicable

Duration (days OR hours)Fever

Cough

Difficult breathing

Diarrhoea

Convulsion

Lethargy

Unconscious

Not able to drink/feed


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10a. Symptom(s) of current illness leading to death: Continue...

Duration (days OR hours)

/Others, specify: Yellowish discolouration of skin

Since day 5 of l ife


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10b. Treatment(s) received for current illness?

/ Yes, Place of Treatment No. of times:

/a. Hospital

/GovernmentUniversity

Private

Others, specify:

b. Clinic Government

University

Private

Others, specify:

c. Unknown


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10b. Treatment(s) received for current illness? Continue...

No, Reason(s):

/Traditional / complementary treatmentNo transport

Unaware child is seriously ill

Others, specify:

Not Applicable, specify:


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12. Certified Cause of Death in Death Certificate:

SEPTI CAEMI C SH OCK WI TH UNDE RLYI NG BI L I ARY ATRESI A


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13. Cause of Death:

ase or condition directlying to death

(a) septicemia

due to (or as a consequence of)

e c e d en t c a u s e (b) biliary atresia.

bid conditions, if any, giving

to the above cause, stating theerlying condition last


(c )


(d).

er significant conditionstributing to the death, but notted to the disease or conditionsing it

...

...

.


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14. ICD Classification of Cause of Death:

/ Infection & Parasitic Disease

NeoplasmDisease of Blood & Immune System

Endocrine, Nutritional, Metabolic

CNS

Circulatory System

Respiratory

Gastro-Intestinal

Genitourinary Tract


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14. ICD Classification of Cause of Death: Continue...

Conditions from Perinatal Period

/ Congenital Malformation

Injuries & External Causes

Symptoms, signs & abnormal findings, not elsewhere classified

Others

Specify Details:

Congeni tal bil iary atresia


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15. Is Death Preventable?

/ Yes

/Patient & Family FactorPeripheral / Referral Centre

Transport Problem

Department / Treatment Problem

Others

Specify Details:


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15. Is Death Preventable? Continue...

No

Not Sure16. Comments:


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CASERN :

Name : TENGKU NUR AMALINA BT TG. M.TARMIZIMy Kid : 130507060586 (F)Address : NO.9 KG. PANJANG BANGGU,

16150 KOTA BHARUAge : 5 MONTHS 19 DAYSDate of birth : 07/05/2013 @1300Date of Admission: 11/09/2013

Date of death : 26/10/2013 @ 1800hDeath classification : SEPTICAEMIC SHOCK WITH UNDERLYINGBILIARY ATRESIA

Birth weight : 2.45 kg


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ANTENATAL CARE

Mother 30 years old, married, G4 P3 Booking at KK BALOK on 5/11/2012, SOD, POG 11 weeks, B/P:

120/70 mmHg, Wt : 64.2kg, Urine Alb/Sug : Neg/ Neg, Hb:

13gm%

Clinic visited : 12 times (antenatally uneventful)

HIV : Non- reactive Hep B : Non- reactive

VDRL : Non-reactive Hep C : Non-reactive

Previous antenatal history : uneventful

LMP : 20/8/2012 EDD : 27/5/2013, REDD 14/5/2013( early

scan at 14w)


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Cont

Associated condition Yes No Unknown

Hypertensive Disorders of Pregnancy

Diabetes Mellitus

Vaginal Bleeding

Anemia in Pregnancy

Prolonged Rupture of Membrane

Preterm Labor

Heart Disease (Mild MVP)


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DELIVERY Delivery in HTAA on 7/5/2013 @ 1300H, 39W, via SVD

Baby Girl Birth weight : 2.45kg

Length: 48cm

COH : 31cm

A/Score : 8/9

G6PD : Normal, cord blood TSH 8.71

Face : normal

Other examinations : Normal

IMP: Asymmetrical SGA


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Homevisit at day 14 noted jaundice, referred to KK, pt refused

At day 15 of life, noted still jaundice at face and chest, still had

rashes.advised to go to KK for prolonged jaundice work up but

husband didnt allow to go to clinic for blood taking.

At day 20 of life, baby well, still had rashes, no jaundice noted

,otherwise child breast feeding well.

Baby gaining weight throughout follow up. Pt attended clinic visit for RME 1 month. Seen by MO, no fever/URTI

sx/vomiting/loose stool/feeding well, grossly normal baby. Wt : 3.4 kg

(gain 1kg of BW)

At 2 month old, seen by SN for immunisation and nil of complaint and

no jaundice noted. (wt 4.0kg)


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CHRONOLOGY ON ADMISSION TO HRPZ II, KB

Problem list: Biliary atresia Type III Portal Hypertension secondary to chronic liver disease ARDS secondary to stenotrophomonas sepsis with multiple

episode of pulmonary hemorrhage Candidiasis sepsis CMV reactive Klebsiella sepsis


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1. Biliary Atresia Type III

History of jaundice since day 5 of life notedupon home visit, advice for proper check up atKK Balok , parents refused. Never beenadmitted for phototherapy before.

Parents migrated to Kelantan, referred fromKK Kedai Lalat for prolonged jaundice. Upon

admission , noted the child having pale colorstool, tea colored urine and deep jaundice.


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Underwent Kasai Prosedure on 19.9.2013 (failed)

Intraop finding: gall bladder atretic, liver enlarged withcirrhosis, fibrosed tissue Developed periportal hypertension and ascites Persistent jaundice, with distended abdomen, and dilated

veins, hepatomegaly Episodes of RT aspirate with blood, possible varices? Increased total bilirubin, impaired liver enzymes Regular IV vit K 1mg OD On IV lasix and syp spironolactone


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2. ARDS secondary toStenotrophomonas sepsis

Ventilated for 21 days (conventional + HFOV) Blood C&S on 26.0.2013- Stenotrophomonas Maltophilia (MRO) TA C&S on 8.10.2013:- Sternotophomonas Maltophilia Antibiotics:- IV Levofloxacin 50mg BD x 10d- IV Vancomycin 50mg QID x 10 d- IV Imipinem 105mg TDS x 10d- IV Bactrim 20mg BD x 14d


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Repeated blood C&S on 30.9.2013 and 17.10.2013: No growth Multiple episodes of pulmonary hemorrhage-blood stain

during suctions Required multiple FFP transfusion Extubated on 20.10.2013 T/O to Anggerik on 21.10.2013 Under nasal prong 2L/min, baseline RR : 40-50 breath/min,

oxygenation maintain >95%


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3. Candidiasis sepsis

Urine C&S on 1.10.2013 : Candida albicans Fungal C&S on17.10.2013 : no growth

On IV amphotericin for 19 days Repeated urine C&S on 10.10.2013 : no

growth


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4. Cytomegalovirus infections

CMV reactive No antiviral


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Upon review in Anggerik on22.10.2013

Fairly stable, afebrile Mildly tachypnoeic with recessions Tolerating infusion feeding and was on TPN

Plan:- To isolate patients had risk to spread infection to other

patients and to other patients other nosocomial infections- Cont. surgical managements (started IV EES)

** at 8pm : patients has transfer to ward 1 as condition moretachypnoeic, less active, vital sign stable


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Progression in ward 1 (22.10.2013 25.10.2013)

Had intermittent low grade fever especially inthe afternoon (37.5-37.9C)

Tachypnoeic, RR : 40-50 No desaturation, SPO2 > 95% Tolerating infusion feeding

More active upon handling Altered sleep pattern, more active at night


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Examination:- Vital sign stable

- Good urine output, glucometer stable- Jaundice, cachexic, alert, responsive to

surrounding- Lung: transmitted sound- CVS: dual rhythm, no murmur- Abd: soft, distended, multiple dilated veins,

hepatomegaly about 6cm, firm, nodularsurface.splenomegaly about 3c m


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Investigations:- hyponatremia, septic parameters improving Management:- Na supplement in infusion feeding and TPN

- Antibiotics off on 23.10.2013

- Physiotherapy- Step up infusion feeding- Plan to restart antibiotic if condition worsening, persistent

spiking of fever


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26.10.2013 at 7.20am (morningreview by passive on call MO)

- Tolerating feeding well- No vomiting, no feverExaminations:

Alert, mild tachypnoiec, dry, jaundiceBP: 101/53 HR: 131 RR: 36r/minT: 37CLung: transmitted soundPer abdomen: soft, distended, liver and spleen palpablePlan:To increase feedingRepated FBC/BUSE and to inform result


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26.10.2013 at 2.30pm Patient cough out blood, blood streak secretions from nostril More tachypnoeic, laboured breathing Temperature spike to 38.2C Spo2 desturated 80% under NP 2L/min Manual bagging, Spo2 85-95%. Intubated due to respiratory

distress IV NS bolus 10ml/kg Noted few episodes of bradycardia then started IV dopamine

infusion 5mcg/kg/min Transfer out to PICU


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Upon arrival to PICU Connect to ventilator, unable to maintain saturations (80-85%) Manual bagging commented Developed massive pulmonary hemorrhage, suctions blood

continuosly from ETT x2 Poor perfusions: given IV NS bolus upto 40ml/kg Transfused PC 10ml/kg Started IV dopamin infusion 20mcg/kg/min Increased IV Dobutamin 20mcg/kg/min Noted patient bradycardia, HR 55 CPR commenced for 30 min


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Resuscitated with- IV adrenalin 1:10000 x 5- IV sodium Bicarbonate 5:5 x 1- IV Calcium gluconate 5:5 x 1 Unable to revived pt Pronouced death at 6.00pm COD: Septicemic shock with underlying biliary

atresia


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DATE 17.10.2013 21.10.2013 24.10.2013 26.10.2013

ALB/GLOB 24/23 27/25

TP 66 52 53

BIL 390 213 377

ALP 255 213 259

ALT 166 147 128

AST 355 201 356

PH 7.45 6.56

PCO2 40 60

PO2 96 30

HCO3 27 9.1

BE 3.9 -28

LACTATE 15


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C&S DATE RESULTBlood 17.9.2013 Coagulase neg staph

Blood 20.9.2013 NG

Blood 26.9.2013 StanotrophomonasmatrophiliaSensitivity:Levofloxacin,bactrim,monocyclineResistence: Imipinem,

tetracyclinBlood 30.9.2013 NG

Blood 17.10.2013 NG

Blood for fungal 17.10.2013 NG


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C&S Date Result

Urine 26.9.2013 NG

Urine 1.10.2013 Candida albican

Urine 4.10.2013 Candida albican

TA 8.10.2013 StanotrophomonasmaltophiliaS: BatrimR: imipinem, tetracycline,minocycline

TA 20.10.2013 Acinobacter spS: unasyn,ceftazidime,ciprofloxacin,gentamycinIntermdediate: pepracilin

Klebsiella pneumonia:S; augmentin,cefotaxime, gentamycin,bactrimR: ampicillin


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Investigations Date Result

BLOOD C&S 26.10.2013 Klebsiella ozaneeS: augmentin, ceforoximeBactrim, gentamycin

Intermediate: ampicillinIntracardiac blood 26.10.2013 NG

LP 26.10.2013 Appearance: clear andcolourlessNo cell countGram stain: no organismseenC&S: NGIndian ink: NEGProtein : Normal


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Death: preventable

- Early detection of biliary atresia, early surgical

procedure may improve prognosis- Sepsis maybe improved if early intervention upon

septic parameter and clinical symptomsworsening, and appropriate antibiotics should bestarted accordingly

Issues:- Isolate pt

- Infectious control to prevent nosocomial infection


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Presentation Utk State Meetng ( DR DAUD)

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