Fascinating case and great work with aggressive fluid resuscitation
during the "golden first hour" of resuscitation, that we as PEM's all
By conventional wisdom, we provide emperic antimicrobial coverage for
neonatal "bugs" upto age 3 months. Since this infant's post gestational
age is 2 weeks, I would extend my purely speculative thinking to concur
with your suggestion of this being a "micropremie" disease.
I am also intrigued by the management of fluid refractory shock in this
case. The clinical presentation, as well as high likelihood of having been
on chronic steroids for CLD, would place this little one at high risk for
adrenal insufficiency. May I suggest, if you have not already
administered, emperic hydrocortisone therapy in stress doses.
One of my areas of clinical and research interests is point of care
focused echocardiography in undifferentiated shock. In this case, an
early ECHO, that you may have already obtained, might assist you with
ongoing management of shock. CLD places this patient at risk for
pulmonary HTN and myocardial dysfunction. Besides, you could rapidly
exclude two additional causes of fluid refractory shock
(1)hemodynamically significant pericardial effusion and
(2)non invasively assess vascular filling i.e. if your 80 cc/kg has
indeed "filled the tank"
The chest radiograph may be a challenge to interpret with chronic
parenchmal changes. If you have a CVL in place I am curious what the
initial CVP & mixed venous sat was?
I would perform an LP if the patient is stable and sepsis related
coagulopathy has been excluded. Presence of meningitis would impact
Would appreciate some feedback on the case.
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