Steroids -Frusemide

Dom Barton is given 1mg/kg of Frusemide and it is prescribed regularly three times a day.

Within a few hours his nurses note that he has a very wet nappy, and a little later that his breathing is easier, with better oxygen saturation levels than before the diuretic.

You reexamine him:

Respiratory: RR 35/min, minimal recession, equal chest movement. Clear chest. SaO₂ 98% in 35% oxygen.

Cardiovascular: HR 140/min, good capillary refill time. Bounding pulses and easy to feel femoral arteries. BP 85/30, Heart sounds normal, with an unchanged systolic murmur still heard under the left clavicle.

Because of the change in fluid turnover, you take some blood to check the electrolytes at the end of your shift.

The following day, at the consultant ward round the results are reviewed:

Urea    3.8 mmol/L

Na       141 mmol/L

K         3.3 mmol/L

Creat   31  micromol/L

The consultant is pleased with the progress and suggests that some spironolactone is added to the frusemide to reduce potassium loss. She also suggests that an echocardiogram is requested to confirm that Dominic has a patent ductus arteriosus, as this is likely to need treatment with ibuprofen.

You next meet baby Dominic Barton when he is three weeks old; he has done well and is preparing to go home and you have been asked to do his discharge check. His nurse notes that he has an inspiratory breathing noise from time to time. She also thinks he has become a little jaundiced.

Since you last saw him, he has had an echocardiogram. This showed a normal heart, but with a large patent ductus arteriosus, shunting left to right. He was treated with ibuprofen in addition to the diuretic treatment, and he improved, coming off oxygen and the diuretics. A follow up echo showed that the ductus had closed.

He is now feeding well independently and his mother has established him on breast milk. He is now off all medication apart from vitamins. His parents are keen to get him home as soon as possible.

They have looked up some of his treatments on the internet and are concerned that the steroids that he had in the immediate newborn period may have affected his growth and brain development.

Mild jaundice, visible in sclera and on skin. Nappy – yellow urine and slightly pale stool. Weight 1.80 kg.

Respiratory: RR 30/min, no recession, equal chest movement. Clear chest. SaO₂ 98% in air. Stridor when upset.

Cardiovascular: HR 135/min, good capillary refill time. Normal

femoral arteries. BP 85/40, Heart sounds normal, no murmurs heard.

Abdominal: Full, but soft on palpation, liver edge palpable at 2cm below costal margin, no other organs felt.

Neurological: Active and alert, moving all limbs. Able to fix eyes on objects. Anterior fontanelle soft.

His right leg appears swollen compared to the left, although the perfusion and pulses are normal.

You arrange an ultrasound of the leg veins to look for a deep venous thrombosis.

What is the most appropriate action at this stage?

A         Check bilirubin and discharge if not requiring phototherapy, see in clinic next week.

B         Check bilirubin (split into conjugated and unconjugated), liver function tests, direct combes test, thyroid function test and urine culture; keep as inpatient until these results are available.

C         Check bilirubin, then transfer to liver specialist centre