Download - Presentation Utk State Meetng ( DR DAUD)
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
1/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
2/45
SECTION 1:
Patient Details
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
3/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
4/45
SECTION 2:Patient Death Details
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
5/45
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:
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
6/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
7/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
8/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
9/45
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:
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
10/45
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
11/45
12. Certified Cause of Death in Death Certificate:
SEPTI CAEMI C SH OCK WI TH UNDE RLYI NG BI L I ARY ATRESI A
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
12/45
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
due to (or as a consequence of)
(c )
due to (or as a consequence of)
(d).
er significant conditionstributing to the death, but notted to the disease or conditionsing it
...
...
.
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
13/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
14/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
15/45
15. Is Death Preventable?
/ Yes
/Patient & Family FactorPeripheral / Referral Centre
Transport Problem
Department / Treatment Problem
Others
Specify Details:
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
16/45
15. Is Death Preventable? Continue...
No
Not Sure16. Comments:
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
17/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
18/45
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)
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
19/45
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)
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
20/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
21/45
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
22/45
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)
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
23/45
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
24/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
25/45
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.
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
26/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
27/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
28/45
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%
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
29/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
30/45
4. Cytomegalovirus infections
CMV reactive No antiviral
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
31/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
32/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
33/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
34/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
35/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
36/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
37/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
38/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
39/45
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
40/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
41/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
42/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
43/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
44/45
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
-
8/12/2019 Presentation Utk State Meetng ( DR DAUD)
45/45