PSH EXIT EXAM

1st CASE
G3P2(multiparity), RBOW >23 hours, normal v/s, baby with jaundice down to abdomen,
antibiotics 4 hours prior to delivery.

1. Give your impression: Neonatal Sepsis (early onset)

2. Basis for your impression: (2) multiparity, ROM >23 hours
● Early-onset sepsis is defined as the onset of symptoms before 7 days of age, although
some experts limit the definition to infections occurring within the 1st 72 hr of life.
● Early-onset infections are acquired before or during delivery (vertical mother-to-child
transmission).
● Late-onset sepsis is generally defined as the onset of symptoms at ≥7 days of age.
Similar to early-onset sepsis, there is variability in the definition, ranging from an onset at
>72 hr of life to ≥7 days of age.
● Late-onset infections develop after delivery from organisms acquired in the hospital or
the community.
● The age at onset depends on the timing of exposure and virulence of the infecting
organism.
● Very-late-onset infections (onset after age 1 mo) may also occur, particularly in
very-low-birthweight (VLBW) preterm infants or term infants requiring prolonged neonatal
intensive care.
Jaundice and Hyperbilirubinemia in the Newborn
● Hyperbilirubinemia is a common and, in most cases, benign problem in neonates.
● Jaundice is observed during the 1st wk after birth in approximately 60% of term infants
and 80% of preterm infants.
● The yellow color usually results from the accumulation of unconjugated, nonpolar,
lipid-soluble bilirubin pigment in the skin.
 ● This unconjugated bilirubin (designated indirect-acting by nature of the van den Bergh
reaction) is an end product of heme-protein catabolism from a series of enzymatic
reactions by heme-oxygenase and biliverdin reductase and nonenzymatic reducing
agents in the reticuloendothelial cells.
● It may also be partly caused by deposition of pigment from conjugated bilirubin, the end
product from indirect, unconjugated bilirubin that has undergone conjugation in the liver
cell microsome by the enzyme uridine diphosphoglucuronic acid (UDP)–glucuronyl
transferase to form the polar, water-soluble glucuronide of bilirubin (direct-reacting).
● Jaundice that is present at birth or appears within the 1st 24 hr after birth should be
considered pathologic and requires immediate attention.
● Potential diagnoses would include erythroblastosis fetalis, concealed hemorrhage,
sepsis, or congenital infections, includiang syphilis, cytomegalovirus (CMV), rubella, and
toxoplasmosis.
● Hemolysis is suggested by a rapid rise in serum bilirubin concentration (>0.5 mg/dL/hr),
anemia, pallor, reticulocytosis, hepatosplenomegaly, and a positive family history.
● An unusually high proportion of direct-reacting bilirubin may characterize jaundice in
infants who have received intrauterine transfusions for erythroblastosis fetalis.
● Jaundice that first appears on the 2nd or 3rd day is usually physiologic but may
represent a more severe form.
● Familial nonhemolytic icterus (Crigler-Najjar syndrome) and early-onset breastfeeding
jaundice are seen initially on the 2nd or 3rd day.
● Jaundice appearing after the 3rd day and within the 1st week suggests bacterial sepsis
or urinary tract infection; it may also be caused by other infections, notably syphilis,
toxoplasmosis, CMV, and enterovirus.
● Jaundice secondary to extensive ecchymosis or blood extravasation may occur during
the 1st day or later, especially in premature infants.

At what age did the direct hyperbilirubinemia occur? (Gomella)

1. Early-onset conjugated hyperbilirubinemia (≤14 days). More likely due to nonhepatic causes
and more infants were likely to be sick. Causes include: multifactorial liver injury (eg, antibiotics,
TPN, sedatives, mechanical ventilation, surgery), sepsis, inborn error of metabolism, idiopathic,
biliary atresia, choledochal cyst. 2. Late-onset conjugated hyperbilirubinemia (15–28 days).
Idiopathic, multifactorial liver injury (eg, antibiotics, TPN, sedatives, mechanical ventilation,
surgery, inotropic support), biliary atresia, sepsis, cytomegalovirus (CMV) infection/choledochal
cyst, inborn errors of metabolism.
3. Presence of direct hyperbilirubinemia immediately after birth (within hours or few days) may
be secondary to congenital infection, hemolysis (with biliary sludging), gestational alloimmune
liver disease, genetic disorders, or inborn errors of metabolism.
4. Presence of direct hyperbilirubinemia after feedings are established suggests that a
metabolic disorder such as galactosemia may be present.
5. Onset of jaundice in an asymptomatic infant after the first week of life may be secondary to
an underlying infection such as urinary tract infection.
2nd CASE
(+)BM 3-5x, (+)vomit 3x previously ingested food, PE sunken eyes, drink fluids eagerly, moist
lips and mucosa, good skin turgor and mobility. Wt 23kg
1. Impression: AGE with Some dehydration
2. Compute Holiday Segar
DEHYDRATION/FLUIDS

Criteria for discharge of newborn (7)

Drug computation: cefuroxime 250mg/5ml (RD 20-40mkD), wt 14, write your prescription
Vaccines:
BCG - primary dose, schedule and route
● BACILLE CALMETTE GUERIN (BCG)
● Given intradermally (ID)
● The dose of BCG is 0.05 ml for children < 12 months and 0.1 ml for children ≥ 12 month
● Given at the earliest possible age after birth preferably within the first 2 months of life
Hep B - primary dose, schedule and route
● Given intramuscularly (IM)
● Administer the first dose of monovalent HBV to all newborns ≥2kgs within 24 hours of life
● A second dose is given 1-2 months after the birth dose
● The final dose is administered not earlier than 24 weeks of age
● Another dose is needed if the last dose was given at age <24 weeks For infants born to
HBsAg (+) mothers (preterm or term infants):
● Administer HBV* and HBIG (0.5ml) within 12 hours of life. HBIG should be administered
not later than 7 days of age, if not immediately available. For infants born to mothers with
unknown HBsAg status:
● With birth weight ≥2 kgs, administer HBV within 12 hours of birth and determine the
mother’s HBsAg as soon as possible. If HBsAg (+), administer HBIG not later than 7
days of age.
● With birth weight <2 kgs, administer HBIG in addition to HBV* within 12 hours of life
● *For infants born <2 kgs, the 1st dose received at birth is not counted as part of the
vaccine series. Additional 3 HBV doses are needed

HiB - primary dose, schedule and route

● Given intramuscularly (IM)
 ● Given as a 3-dose primary series with a minimum age of 6 weeks and a minimum
interval of 4 weeks
● A booster dose is given between age 12-15 months with an interval of 6 months from the
third dose

Rota - primary dose, schedule and route

Human (RV1)
● Given per orem (PO) as oral liquid formulation
● Given as a 2-dose series
● Given at a minimum age of 6 weeks with a minimum interval of 4 weeks between doses.
● The last dose should be administered not later than 24 weeks of age.

Human-Bovine live-attenuated reassortant (RV5) (oral liquid formulation)

● Given per orem (PO)
● Given as a 3-dose series
● First dose is given at age 6-12 weeks, with a minimum interval of 4-10 weeks between
doses.
● The last dose should not be administered beyond 32 weeks of age.

Human-Bovine live-attenuated reassortant (RV5) (oral freeze-dried formulation)

● Given per orem (PO)
● Given as a 3-dose series, recommended at 2, 4 and 6 months
● Given at minimum age 6 weeks with a minimum interval of 4 weeks between doses
● The last dose should not be administered beyond 12 months of age.
Measles - primary dose, schedule and route
● Given subcutaneously (SC)
● Given at the age of 9 months, but may be given as early as age 6 months in cases of
outbreaks as declared by public health authorities
● If monovalent measles vaccine is not available, then MMR/MR vaccine may be given as
substitute for infants below 12 months of age.
● In such cases, the recipient should receive 2 more MMR vaccines starting at 1 year of
age, following recommended schedules
SEPSIS CARE BUNDLES
To be completed
within 3 hr
1. Measure lactate level.
2. Obtain blood cultures before administration of antibiotics.
3. Administer broad-spectrum antibiotics.
4. Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
To be completed within 6 hr:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to
maintain a mean arterial pressure (MAP) ≥65 mm Hg.
6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or
initial lactate ≥4 mmol/L (36 mg/dL):
Measure central venous pressure (CVP).*
Measure central venous oxygen saturation (ScvO2).*
7. Remeasure lactate if initial lactate was elevated

COMPUTATION:

Ex.
Paracetamol 120/5ml
So, 120/5 x ml (to give) / wt (wt of the child)