DIAPHRAGMATIC HERNIA

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DIAPHRAGMATIC HERNIA : 

DIAPHRAGMATIC HERNIA

Slide 2: 

44 DAYS old male child B/o savitra irpate borne by emergency LSCS on 31st july 07 at 5.15 pm , indication being previous LSCS with overdue by 12 days. The mother 30 yrs old, illiterate, belonging to low socioeconomic status, residing at pachod, arvi, wardha, earn by daily wages, having blood group 0 rh positive, is gravida 2, was admitted hrogh casualty with chif complaints of leaking p/v and abdominal pain since morning of the day of admission. She was directly in the emergency O.T. in vies of the overdue by 12days and previous LSCS. The antenatal history was insignificant, she attended the ANC clinics regularly in the PHC, received the iron and folic acid prophylaxis during this period, was transferred to AVBRH at term.

BIRTH HISTORY : 

BIRTH HISTORY Delivered by emergency LSCS Not cried imidiatly after birth. Baby was received in the prewarmed towel, dried, and kept under the warmer. Aftr proper positioning, suction was done and tactile stimulation was given but the spontaneous respiration was not initiated so bag and mask was given after which spontaneous respiration was initiated. The heart rate improved from 60/min. to 138/min. He respiratory efforts improved but there were intercostal and subcostal retractions so he was shifted to NICU.

NICU STAY : 

NICU STAY Shifted from the emergncy O.T. in view of – 1. Moderate birth asphyxia ( apgar 5/10, 7/10, 8/10 ) 2. Respiratory distress at birth 3. Postterm overdue by 12 days. On admission to nicu G.C. was unsatisfactory Baby as hypothermic acrocyanosis + respiratory distress + ICR, SCR + nasal flaring +

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peripherals well felt CRT < 3 secs H.R. 148/min. R.R. 46/min. C.V.S. - S1 S2 normal no obvious murmur no gallop R.S. - air entry was reduced on the left side. B/L crepts + C.N.S. – C/T/A poor Moros incomplete only abduction no adduction P.A. - soft, nondistended.

INVESTIGATIONS : 

INVESTIGATIONS Hb - 18.3gm/dl TLC – 13200 p/52 l/45 RBS – 68 mg/dl CRP - negative Culture ( blood ) – coag. Positive staph sensitive to vancomycin microESR – 3mm / 1st hr X ray -

SUMMARY OF DAY 1 : 

SUMMARY OF DAY 1 BABY WAS KEPT ON O2 BY HOOD AS HE WAS NO MAINTANING THE SATURATION. THE X RAY WAS SUGGESTIVE OF THE CONSOLIDATION. HE WAS TREATED AS CONGENITAL PNEUMONIA HE WAS ON CTAX AND AMIKACIN, IV FLUIDS 2/3RD RESRTICTED, O2 BY HOOD. ABG WAS TRIED BUT ABG MACHINE WAS NOT WORKING.

DAY 2 : 

DAY 2 UNEVENTFULL. DISTRESS STILL PRESENT. NOT ABLE TO WEAN OFF O2. ABG MACHINE STILL NOT WORKING. CONTINUED WITH SAME MANAGEMENT.

DAY 3 : 

DAY 3 DISTRESS STILL PRESENT. TACHYPNOEA , TACHYCARDIA STILL PRESENT. NO IMPROVEMENT IN GENERAL CONDITION OF THE PATIENT. BLOOD CULTURE WAS SUGGESTIVE OF COAG +VE STAPH. SENSITIVE TO VANCOMYCIN SO ANTIBIOTICS WERE STEPPED UP TO CFTAZIDIME AND VANCOMYCIN AND TEATED AS CONGNITAL PNEUMONIA.

INVESTIGATIONS : 

INVESTIGATIONS HB – 18.3 GM/DL TLC – 4100 P/45 L/52 PLATELETS – 2,25,000. ELECTROLYTES- NA/130,K/4.1, UREA/41, CREAT/0.60. X RAY- S/O CONSOLIDATIONS.

DAY 4,5 : 

DAY 4,5 AS CULTURE WAS POSITIVE PLANNED TO EPEAT CULTURE AND SEPSIS SCREEN AFTER 48 HRS OF THE ANTIBIOTICS. NO IMPROVEMENT IN GENERAL CONDITION, TACHYPNOEA STILL PRESENT. TACHYCARDIA SETTLED. URINE OUTPUT WAS ADEQUETE.

DAY 6,7 : 

DAY 6,7 NO IMPROVEMENT IN GENERAL CONDITION DISTRESS STILL PRESENT X RAY WAS REPEATED AND SECOND CULTURE WAS ALSO POSITIVE FOR STAPH SENSITIVE FOR VANCOMYCIN. SO SAME MANAGEMENT CONTINUED.

INVESTIGATIONS : 

INVESTIGATIONS HB – 17.2 GM/DL TLC – 8300 P58, L35 PLATELETS – 52000 BLOOD CULTURE - +VE FOR COAG. POSITIVE STAPH. SENSITIVE TO VANCOMYCIN CRP – POSITIVE INITIALLY NEGATIVE. X RAY – S/O GASTRIC SHADOW IN THE CHEST ?DIAPHRAGMATIC HERNIA ?? EVENTRATION OF DIAPHRAGM

DAY 8 : 

DAY 8 SURGERY CALL DONE ADVICED BARIUM TO CONFIRM THE DIAGNOSIS . ALSO ADVICED PAEDIATRIC SURGEONS ADVICE. DISTRESS STILL PRESENT CANNOT WEAN FROM THE O2

DAY 9 : 

DAY 9 GENERAL CONDITION WAS SAME. NO IMPROVEMENT IN RESPIRATORY DISTRESS WAS ON O2 BY HOOD. BARIUM XRAY – S/O EVENTRATION OF DIAPHRAGM.

DAY 10 : 

DAY 10 SHIFTED TO EMERGENCY O.T. FOR REPAIR OF TH HERNIA EVENTRATION. SURGERY WAS DONE BY TH PAEDIATRIC SURGEON AND HIS TEAM. OPERATIVE PROCEDURE – UNDER AAP UNDER G/A ABDOMEN WAS OPENED THROUGH SUBCOSTAL INCISION THE HERNIA WAS REDUCED AND THE DIAPHRGMAIC DOME WAS PLICATED WIH PROLINE. AFTER CONFIRMING THER WAS NO MALROTATION ABDOMEN WAS CLOSED IN LAYERS

POST -OP X RAY : 

POST -OP X RAY

DAY 11,12,13 : 

DAY 11,12,13 TACHYPNOEA WAS SETTLED AS COMPAIRED TO INITIAL. BUT STILL ON O2 NOT ABLE TO WEAN OFF O2 URINE OUTPUT WAS ADEQUETE. THE GENERAL CONDITION ALSO IMPROVED AS COMPAIRED TO INITIAL.

DAY 14,15 : 

DAY 14,15 HE WAS STARTED ON NG FEED. DISTRESS STILL PRESENT BUT LESS AS COMPAIRED. NOT ABLE TO WEAN OFF THE O2. HE TOLERATED THE NG FEED WELL SO HE WAS STARTED ON KC FEEDING.

DAY 16,17,18,19 : 

DAY 16,17,18,19 TOLERATED THE FEEDS WELL. DISTRESS REDUCED BUT STILL OXYGEN DEPENDENT SEPSIS SCREENING REPEATED. URINE OUTPUT WAS ADEQUETE. PALLOR PRESENT.

DAY 20-22 : 

DAY 20-22 C/O VOMITINGS AFTER FEEDS SO STARTED ON DOMPERIDON DROPS TO WHICH HE RSPONDED AND THE VOMITINGS STOPPED ON DAY 22. BUT HE STILL WAS OXYGEN DEPENDENT. SO THE DIAGNOSIS OF BRONCHOPULMONARY DISPLASIA WAS SUSPECTED AND HE WAS STARTED ON VIT. E AND SHORT COURSE OF STEROID THERAPY.

DAY 26 : 

DAY 26 THERE WAS NO IMPROVEMENT IN THE REQUIEMENT OF OXYGEN AND HE STILL WAS OXYGEN DEPENDENT. NO RESPONSE TO STEROIDS, SO SUSPECTE OF THE PRIMARY PULMONARY HYPERENSION AND PLANNED TO START HIM ON TAB. SILDENAFYL (0.5MG/KG/DOSE) ECHO WAS ALSO ADVICED.

DAY 27 : 

DAY 27 ECHO WAS DONE S/O CONGENITAL HEART DISEASE– ASD (LEFT TO RIGHT SHUNT ) WITH RIGHT PULMONARY ARTERY BRANCH STENOSIS MODERATE GRADE. CONTINUED WITH TAB. SILDENAFYL AND VIT. E THERAPY. HIS DISTRESS DECREASED BUT HE STILL WAS O2 DEPENDENT. HE WAS PALE AND HIS HEMOGLOBIN LEVELS FALL TO 8.8 GM/DL.

DAY 30 : 

DAY 30 NOT ABLE TO WEAN OFF O2 DISTRESS STILL PRESENT SO DOSE OF TAB. SILDENAFYL INCREASED TO 0.75 MG/KG/DOSE. BOWEL AND BLADDER HABITS ARE NORMAL.

DAY 34,35,36 : 

DAY 34,35,36 HE WAS GIVEN BLOOD TRANSFUSION AS HIS FINACIAL CONDIION WAS NOT GOOD HE RECEIVED BLOOD TRANSFUSION LATE. HIS COLOR IMPROVED AND HE STARTED MAINTAING SATURATION ABOVE 80% FOR THE FIRST TIME. INTERMITTENT O2 THERAPY STARTED AND TAB SILDENAFYL CONTINUED.

DAY 37,38,39 : 

DAY 37,38,39 INTERMITENT O2 HERAPY RESPONDED AND HE STARTED MAINTAINING SATURATION OFF O2 UPTO 88%. GENERAL CONDITION IMPROVED AND HE WAS STARTED ON BREAST FEEDING. HE ACCEPTED BREAST FEED WELL. KEPT ON TAB. SILDENAFYL AND MULTIVITAMIN DROPS

DAY 43,44 : 

DAY 43,44 BABY WAS OFF O2 MAINTAINING SATURATION UPTO 88% -92%. HE WAS TOLERATING BREAST FEED WELL. HE WAS DISCHARGED ON – TAB. SILDNAFYL HOVITE DROPS FERIUM XT DROPS

X-ray ON DISCHARGE : 

X-ray ON DISCHARGE

FINAL DIAGNOSIS : 

FINAL DIAGNOSIS FULL TERM /AGA/ MALE CHILD/BORNE BY EMERGENCY LSCS/ WITH MODERATE BIRTH ASPHYXIA WITH RESPIRATORY DISTRESS WITH EVENTRATION OF DIAPHRAGM ? DIAPHRAGMATIC HERNIA WITH CONGENITAL HEART DISEASE ( ASD WITH LEFT TO RIGHT SHUNT ), WITH RIGHT PULMONARY ARTERY BRANCH STENOSIS MODERATE GRADE WITH ? PRIMARY PULMONARY HYPERTENSION.

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