OSPITAL NG MAYNILA MEDICAL CENTER Department of Pediatrics Quirino Ave. corner Roxas Blvd., Malate, Manila
Name: ANAS, WAHIDA ROSENDE Age/Sex: 5/F Address: 649 Baseco Port Area Mla Date Admitted: 5/30/09 Admitting Diagnosis: Dengue hemorrhagic fever grade III Residents-in-charge: Drs. C. Nunez/Cortes/Reyes/Arimao
Hospital No.: 1993705 Room: NICU
Death Protocol This is a case of a 5 year old female born from a who was brought in due to vomiting. History of Present Illness: 2 days PTA, the patient experienced fever (undocumented) and vomiting of previously ingested food. No consult was done and no medications were given. 1 day PTA, fever persisted and there were 2-3 episodes/day of non-bilous vomiting, approximately 30ml per episode. It was associated with nonradiating epigastric pain. Consult was done at PMD and was prescribed Cloxacillin, Dicycloverine and Paracetamol which gave no relief. Few hours PTA, there was persistence of fever, vomiting and epigastric pain. It was also associated with non-productive cough. These prompted consult and subsequent admission at our institution. Review of Systems: Patient has poor apetite, no difficulty of breathing, no cyanosis and no chills. Past Medical History: No history of operations or hospitalizations. No known allergies to food or drugs. Family Medical History: (+) HPN-maternal side, (+) BA-maternal side, (-)DM Immunization History: BCG, DPT3, OPV3, Hepa B, (-) measles Personal/social History: The patient lives with 5 other household members in a small ventilated area. They get their drinking water from a water refilling station. The patient is currently in kindergarten and is fond of playing. Physical examination: General: The patient is irritable and not in cardiorespiratory distress Vital signs: HR:86 RR:44 T:37.6 BP:90/60 HEENT: normocephalic, anicteric sclerae, pink palpebral conjunctivae, no cervical lymphadenopathy Chest and Lungs: symmetrical chest expansion, clear breath sounds, no retractions CVS: adynamic precordium, normal rate and regular rhythm, no murmurs Abdomen: flat, soft, non-tender, normoactive bowel sounds Extremeties: no gross deformities, no cyanosis, no edema Genitalia: normal external genitalia Assessment: Dengue Hemorrhagic Fever grade III Plan: Patient was admitted to Pedia-ward PICU under the service of Drs. C. Nunez/Cortes/Reyes/Arimao. Consent for admission and management was secured. Patient was placed on DAT once fully awake and dark colored foods were prohibited. IVF was D5LR 1L to run at 45ugtts/min (3cc/kg). Diagnostics requested were CBC with PC, UA and CXR-AP/L and PFA. Oxygen support via funnel was given prn. Medications
prescribed were Ranitidine 15mg TIV q8h and Paracetamol 250mg/5ml, 5ml q4h prn. Patient was monitored hour and recurrence of abdominal pain, bleeding episodes, and hypotension were watched out for. Course in the wards: On first hospital day(11pm), patient was referred to surgery for further evaluation and management of abdominal pain. VS were monitored every hour and referred if once with hypotension(BP≤70/40) and narrow pulse pressure(difference of 20 or less). Diagnostics requested were serum Na and potassium. nd On same hospital day (12:40am), 2 line was inserted and hooked to PNSS 1L to run at 45ugtts/min (3cc/kg). Fast drip of 150ml PNSS was given immediately. BP monitoring was done after giving bolus. On same hospital day (2:15am), IVF was continued. On same hospital day (2:30am), Dopamine drip (5mcgs/kg) (Dopamine 45mg, D5W-50ml) was given to run at 5ugtss/min. BP monitoring was continued. NGT was inserted and kept open to drain. Diagnostics requested were blood typing/ PT, PTT. BP monitoring was continued. On same hospital day (3:55am), 150ml OF Dextran bolus was given (10cc/kg). Dopamine drip was continued. On same hospital day (7:25am), patient was maintained on NPO. IVF line1 was D5LR 1L to run at 30ugtss/min (2cc/kg) and line2 was PNSS 1L to run at 45ugtss/min (3cc/kg). Oxygen support via funnel at 5-6lpm was maintained. Dobutamine drip (10mcgs/kg) (dopamine-45mg, D5W50ml) was given to run at 10ugtss/min. VS monitoring was done every hour. Hypotension and narrow pulse pressure were watched out for. On same hospital day (7:50am), patient was seen and examined by Dept of Surgery. Pertinent PE findings were abdomen was flat, soft and non-tender and DRE – no skin tags, no anal mucus, tight sphincteric tone, (+) brown stool on examining finger. Assessment was DHF grade III. No surgical intervention was needed at the time of examination. Monitoring of abdominal status was suggested to be continued. On same hospital day (11:25am) dopamine drip was increased to 15ugtss/min. 1’u’ of FWB properly typed and crossmatched was secured. 220ml of FWB was to be transfused to run for 4 hours. IVF line1 and line2 were held. Patient was for CXR. Patient was referred to surgery for CVP insertion. On same hospital day (1pm), dextran 150cc was pushed TIV immediately. On same hospital day(4pm), patient was seen and examined by Dept of Surgery. Materials needed for CVP insertion and procedure were explained. On same hospital day (4:25pm) paracetamol 150mg TIV q4h prn for T≥37.8 was given. On same hospital day (5:10pm) TSB and oxygen support were continued. Patient was maintained on high back rest. Foley catheter was inserted. UO was measured. On same hospital day (5:45pm), Diphenhydramine 15mg TIV was given prior to BT. Furosemide 7.5mg TIV post-BT was given. VS was monitored q30mins. Diagnostic requested was ABGs. On same hospital day (9:30pm), patient was intubated with ET size5 level 1o. Continuous ambobagging was done. On same hospital day (9:35pm), secretions were suctioned, CPR was continued. Epinephrine 1amp TIV was given immediately. On same hospital day (9:40pm) CPR was continued and epinephrine 1amp TIV was given. On same hospital day (9:50pm) patient was pronounced dead and post-mortem care was given.