SENARAI KEMATIAN DIDAWAH UMUR 5 TAHUN PKD KUANTAN OKT DEC 2013

Umur Semasa Mati

Nama Ibu dan No. K/P

Nama Anak

Alamat Tetap

Klinik Berhampiran

Tarikh / Tempat

Kematian ibu

Mati Dalam Perut

0 - 6 Hari 7 - 27 hari

28 - 1 Tahun

1- 4 tahun

5-6 Tahun

Sebab Kematian Dan LainLain Catitan

MAIZATUL AKMA 821119036081

TG NUR AMALINA BT TG TARMIZI

KG CHENGAL LEMPONG

KK BALOK

26/10/13 HOSP KOTA BHARU

6 BULAN

SEPTICEAMIA WITH BILIARY ATREASIA

SECTION 1:
Patient Details

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:

07TH MAY 2013 @1300

SECTION 2:
Patient Death Details

7. 8.

Date & Time of Death: 26/10/ 2013 @ 1800PM Place of Death: / Home Clinic On way to hospital

Others, specify:

PICU HPSZ II

9.

Person Certifying Death: / Medical, specify: MO Non-medical, specify:

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

10a.

Symptom(s) of current illness leading to death: Continue... Duration (days OR hours) / Others, specify: Yellowish discolouration of skin Since day 5 of life

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

/ Yes, Place of Treatment No. of times:

a. Hospital /

Government
University

Private
Others, specify:

b. Clinic

Government
University Private Others, specify:

c. Unknown

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

No, Reason(s):

Traditional / complementary treatment

No transport

Unaware child is seriously ill

Others, specify: Not Applicable, specify:

11. Co-Morbid Condition: Yes Cerebral Palsy Chronic Lung Disease Malnutrition / Congenital Anomaly, specify: Cardiac Disease, specify: Malignancy, specify: Condition from perinatal period, specify: Biliary atresia

Immunodeficiency, specify:
Others, specify:

No

12. Certified Cause of Death in Death Certificate:

SEPTICAEMIC SHOCK WITH UNDERLYING BILIARY ATRESIA

13. Cause of Death:

Disease or condition directly eading to death

(a)septicemia due to (or as a consequence of) (b)biliary atresia . due to (or as a consequence of) (c ) due to (or . as a consequence of) (d).

Antecedent cause

Morbid conditions, if any, giving ise to the above cause, stating the underlying condition last

. Other significant conditions ontributing to the death, but not elated to the disease or condition ausing it

... ...

14. ICD Classification of Cause of Death: / Infection & Parasitic Disease Neoplasm Disease of Blood & Immune System Endocrine, Nutritional, Metabolic CNS

Circulatory System Respiratory Gastro-Intestinal Genitourinary Tract

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:
Congenital biliary atresia

15. Is Death Preventable? / Yes / Patient & Family Factor Peripheral / Referral Centre Transport Problem Department / Treatment Problem Others Specify Details:

15. Is Death Preventable? Continue... No

Not Sure
16. Comments:

CASE
RN Name My Kid Address : : TENGKU NUR AMALINA BT TG. M.TARMIZI : 130507060586 (F) : NO.9 KG. PANJANG BANGGU,
16150 KOTA BHARU

Age : 5 MONTHS 19 DAYS Date of birth : 07/05/2013 @1300 Date of Admission: 11/09/2013 Date of death : 26/10/2013 @ 1800h Death classification : SEPTICAEMIC SHOCK WITH UNDERLYING
BILIARY ATRESIA

Birth weight

2.45 kg

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 VDRL : Non-reactive LMP : 20/8/2012 scan at 14w) Hep B : Non- reactive Hep C : Non-reactive

Previous antenatal history : uneventful

EDD : 27/5/2013, REDD 14/5/2013( early

Cont
Associated condition Hypertensive Disorders of Pregnancy Diabetes Mellitus Vaginal Bleeding Anemia in Pregnancy
Yes No Unknown

Prolonged Rupture of Membrane

Preterm Labor Heart Disease (Mild MVP)

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

POST NATAL
Delivery was informed to KK Balok. Nursing done in 12 times.

No ward admission on slight Jaundice level of face.

Home visit done at day 3,4,5,6,7,8,9,10,11, 14, 15 and 20 Referred to KK for TSB each time home visit but parent refused to go to clinic. Came only once at day 13 of life with TSB that time 131 for

complaint of rashes at body.no fever, dx as allergy/eczema,

given symptomatic treatment.

 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)

CHILD HEALTH DETAILS

DATE 07/5/ 13 10/6/ 13 AGE NB B/W (KG)/ H(cm) / COH(cm) 2.45/48/31 BMI PMKN Growth TCA Noted BCG, Hep B 1st dos given. Health, active, BF good Hep B 2nd dos given, RME done Health, active, BF good Hep B 2nd dos given 13 BF + AF 25/9/13 c/o Jaundice refer MO for c/o

IM (KK Balok)

3.4/54/36

08/7/ 13

2M (KK Balok)

4.0/57/37

20/8/ 3M 13 (KK kdai Lalat. kel)

4.4/59/37

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

1. Biliary Atresia Type III

History of jaundice since day 5 of life noted upon home visit, advice for proper check up at KK Balok , parents refused. Never been admitted for phototherapy before. Parents migrated to Kelantan, referred from KK Kedai Lalat for prolonged jaundice. Upon admission , noted the child having pale color stool, tea colored urine and deep jaundice.

 Underwent Kasai Prosedure on 19.9.2013 (failed) Intraop finding: gall bladder atretic, liver enlarged with cirrhosis, 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

2. ARDS secondary to Stenotrophomonas 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

 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%

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

4. Cytomegalovirus infections
CMV reactive No antiviral

Upon review in Anggerik on 22.10.2013

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 more tachypnoeic, less active, vital sign stable

Progression in ward 1 (22.10.2013 25.10.2013)

Had intermittent low grade fever especially in the 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

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, nodular surface.splenomegaly about 3cm

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

26.10.2013 at 7.20am (morning review by passive on call MO)

- Tolerating feeding well - No vomiting, no fever Examinations: Alert, mild tachypnoiec, dry, jaundice BP: 101/53 HR: 131 RR: 36r/min T: 37C Lung: transmitted sound Per abdomen: soft, distended, liver and spleen palpable Plan: To increase feeding Repated FBC/BUSE and to inform result

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

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

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

Investigations:
Date TWBC NEUT/LYMP HB PLT CRP PT/APTT INR UREA NA K CL CREAT 17.10.2013 17.4 62/25 10.1 202 37.8 13/36 1.1 4.7 159 4.1 101 35 6.5 192 6.2 98 29 18.10.2013 15.14 43/? 14.1 147 116 13/48 1.3 4.6 126(190) 9.5 89 23 12.4 127 4.1 100 95 24.10.2013 14.51 58/25 8.1 110 26.10.2013 65 62/23 4.0 15 179

DATE ALB/GLOB TP BIL ALP ALT AST PH PCO2 PO2 HCO3 BE LACTATE

17.10.2013 66 390 255 166 355

21.10.2013 24/23 52 213 213 147 201 7.45 40 96 27 3.9

24.10.2013 27/25 53 377 259 128 356

26.10.2013

6.56 60 30 9.1 -28 15

C&S Blood

DATE
17.9.2013

RESULT
Coagulase neg staph

Blood
Blood

20.9.2013
26.9.2013

NG
Stanotrophomonas matrophilia Sensitivity: Levofloxacin,bactrim, monocycline Resistence: Imipinem, tetracyclin NG

Blood

30.9.2013

Blood
Blood for fungal

17.10.2013
17.10.2013

NG
NG

C&S Urine Urine Urine

Date 26.9.2013 1.10.2013 4.10.2013

Result NG Candida albican Candida albican

TA

8.10.2013

Stanotrophomonas maltophilia S: Batrim R: imipinem, tetracycline, minocycline

Acinobacter sp S: unasyn, ceftazidime,ciprofloxacin, gentamycin Intermdediate: pepracilin

TA

20.10.2013

Klebsiella pneumonia: S; augmentin, cefotaxime, gentamycin, bactrim R: ampicillin

Investigations BLOOD C&S

Date 26.10.2013

Result Klebsiella ozanee S: augmentin, ceforoxime Bactrim, gentamycin Intermediate: ampicillin NG Appearance: clear and colourless No cell count Gram stain: no organism seen C&S: NG Indian ink: NEG Protein : Normal

Intracardiac blood LP

26.10.2013 26.10.2013

 Death: preventable - Early detection of biliary atresia, early surgical procedure may improve prognosis - Sepsis maybe improved if early intervention upon septic parameter and clinical symptoms worsening, and appropriate antibiotics should be started accordingly Issues: - Isolate pt - Infectious control to prevent nosocomial infection