Back in February we went to the Stollery and requested Noah’s hospital records. We finally received them in April, all 210 pages of them.
Today I got a letter from the University hospital that included the discharge summary from December 29, 2010. Apparently it was unavailable when we requested the hospital records, but it was available now.
December 29, 2010
Noah [last name] was admitted here at 47h of age for management of seizures. He was born to a 19-year-old G1P0 in Grande Prairie. Mom was induced at 40 [actually, 41] weeks gestation. There was meconium staining in the amniotic fluid and variable deceleration. Membranes ruptured one hour prior to delivery. She had a spontaneous delivery after labor of 2.5 hours and a second stage of 1 hour. The baby’s cord pH was 6.9. He was born flat and given Apgar scores of 2 at 1 minute, 7 at 5 minutes. Birthweight 3920 g. He was given PPV [pressure positive ventilation] for 3 minutes and was then started on CPAP. At 15 minutes of age he had a pH of 7.05 and was given sodium bicarbonate. He had a pneumothorax and initial examination showed the baby to be hypotonic. He was also noted to have a caput succedaneum which subsequently subsided and a cephalohematoma was evident. He had a partial septic workup including a lumbar puncture and was commenced on antibiotics. At 30h of age he was noted to have significant apnea with desaturation episodes and was given caffeine. Subsequently, he had seizure activity. He then required endotracheal intubation and was transferred to the […] NICU for further management.
On admission, weight 4 kg, HC 38.74 cm, L 50 cm. On examination, Noah had a large cephalohematoma, he had an extended posture, no suck or gag could be elicited, he withdraws to pain. Other systemic examination was unremarkable. Impression of the team on admission was that he had hypoxic ischemic encephalopathy, Stage 2 to 3. Initial apnea EEG showed severe suppression with periods of bursts in between, together with episodes of seizures. Neurology was consulted and an EEG showed a brief two seizures with a burst suppression pattern. Over the next few days he had seizures that were difficult to control requiring up to a maximum of 50 mg/kg of Phenobarbital, Phenytoin 20 mg/kg, and Midazolam infusion. The prognosis was guarded and a repeat EEG at 10d of age was still abnormal with modified burst suppression pattern.
There has been extended discussion with the parents regarding a long-term prognosis and outcome. Noah was extubated on December 24 with a DNR order in place. The parents and extended family have been in attendance.
Over the next few days his clinical situation has changed. He has been breathing regularly and opening his eyes but remains hypotonic. He has a suck reflex and grasp was weak, arms were flexed and he was responsive to stimuli. After further extensive discussions with the family, they agreed that they would like to continue with palliative care, and offering Noah feedings by bottle. There is no gavage feeding at the current stage.
Given the MRI finding and the abnormal EEG at 10d of age, his prognosis remains quite guarded. He is certainly going to have disability, the extent of which is unclear at this stage. Should Noah survive, he will require follow up with the Glenrose Hospital and a repeat MRI in two to three months’ time. It is also important for Noah to have physiotherapy for range of movement of extremities as he is likely to develop cerebral palsy.
(1) HYPOXIC ISCHEMIC ENCEPHALOPATHY (SARNAT STAGE 2-3)
(2) UNCONTROLLABLE SEIZURES
(3) PALLIATIVE CARE.