CPC SIG CASE PRESENTATION JUNE 2020 Dr Grace

CPC SIG CASE PRESENTATION JUNE 2020 Dr Grace Ng

Case Study • Patient A, newborn baby boy • Antenatally diagnosed gastroschisis • Growth scan (22+4 wks): Very significant portion of the gut of the abdominal cavity • Counseled by pediatric surgeons regarding the diagnosis and possible outcomes • Parents decided to continue with the pregnancy, hopeful that child’s condition would be operable

Case Study • Birth history • Delivered via emergency LSCS at 34 weeks due to premature prolonged rupture of membranes with persistent contractions, dexamethasone completed • Cried at birth, APGAR 9, 9 • Gastroschisis confirmed – abdominal wall defect with evisceration of bowel • Birth weight 1. 8 kg

Case Study • Post natal course • Underwent emergency exploratory laparotomy at 6 HOL • Intra-op findings • Complete midgut strangulation from D 3 to distal transverse colon • Exteriorized bowel ischemic and non-viable • Proximally distended stomach and megaduodenum, distally 10 cm of colon • Deemed non-viable configuration, not a candidate for gut transplant, decision was made for palliative management • Extruded bowel reduced into the abdomen with fascia closure

Case Study • Post natal course • Parents counselled regarding the poor prognosis (days to short weeks) and agreeable with palliative management, decided to bring their baby home. • Pediatric palliative home care team activated to support this family at home

Case Study • Assessment prior to discharge on D 4 OL • Baby is alert and opening eyes • Comfortable on IV morphine infusion 4 mcg/kg/hr via peripheral line • Kept NBM, except for small amounts of colostrum for comfort • NGT in situ, with 4 Hrly aspiration of small amounts of billous contents (1 -2 ml) • Abdomen is soft, not distended, non tender. Wound site clean, with small amount of clear discharge from umbilicus • Nil other congenital abnormalities

Questions for discussion • How would you prepare for this baby’s terminal discharge? • What symptoms (e. g. pain, hunger, gut complications) would you anticipate for and how would you manage them? • How would you prepare and support the family and healthcare providers for these possible scenarios? • Are there any special considerations when providing palliative care to premature babies? • What are some ethical issues to consider in this case (e. g. continuation of nutrition, organ donation)?