Nepal: Kanti Childrens Hospital

Manisha Rana

Age 9

Manisha Rana is a 9-year-old girl from Jajarkot. She was referred from Nepalgunj Medical College and arrived at the Emergency department of Kanti Children’s Hospital on the 9th of March 2018 with complaints of abdominal pain and distention for 3 days. She had multiple episodes of vomiting whatever she ate during the past 3 days and hadn’t passed stool for 2 days. On examination, Manisha’s general condition was both poor and toxic. Her blood pressure was systolic 80 mmHg and diastolic 40 mmHg, and her abdomen was distended. An x-ray of Manisha’s abdomen was done immediately, which showed multiple air fluid levels suggesting intestinal obstruction. Basic blood investigations showed that she had an elevated white blood cell count with neutrophilic predominance. An emergency nasogastric tube insertion and Foley catheterization were done.

Manisha was admitted to the Surgical Intensive Care Unit with ionotropic support and intravenous antibiotics. On her second day of admission, her blood pressure returned to normal, but her abdominal distension and pain didn’t improve. On the third day, she underwent an exploratory laparotomy under general anesthesia. Operative findings included excessively distended bowel loops with band adhesion on the small intestine. The adhesion was released, and decompression was done. Further post-operative course was uneventful. Manisha was then transferred to the Surgical ward on her second post-operative day, i.e. the 14th of March. Dressing of the abdominal incision was done on alternating days, and intravenous antibiotics were continued. On subsequent improvement, she was then discharged on the 21st of March, her ninth post-operative day.

Manisha came for stitch removal on her twelfth post-operative day at the Surgical OPD, and she was feeling well and grateful, with a happy face. She will be returning to her home in Jajarkot after few days.

– Dr. Purushottam Adhikari, RMF Medical Officer, Kanti Children’s Hospital

Dipika Sarki

Age 4

Dipika Sarki is a 4-year-old girl who presented at the Emergency department on the 13th of March 2018, with complaints of abnormal body movement for 2 days and fever for 4 days. Dipika is small for her age and suffers from cerebral palsy. She lives in an NCO orphanage home, where RMF nurses help care for her. According to her caregivers, the child was well 4 days ago, then she gradually developed abnormal body movement and increased in U/L and L/L. Her caregivers also gave her history of a high-grade fever with chills. The rest of the systemic examination was normal, except the CNS examination, due to her HIE C/P sequel.

Dipika was kept in the ER department and was started on IV antibiotics, fluids, and injectable phenytoin. Then the team sent all the baseline investigations for analysis. After an hour, the child was still having seizures, and we repeated the dose of phenytoin. Dipika still had recurrent seizures that were not controlled by the medication, and she developed a high respiration rate and was not maintaining sufficient oxygen saturation with a face mask oxygen supply. The team continued close monitoring of the child. As she was brought from an orphanage home, her caregiver didn’t have enough money to buy medicine.

Dipika needed ICU care, so we shifted her to the Pediatric ICU and started treatment there. On her second day of PICU admission, abnormal movement still persisted, and our team upgraded the IV antibiotics and added more anticonvulsive drugs. Later, on the third day, she was more stable. After that, IV fluids were discontinued, but she was kept on NG feeding. An eye consultation was also done, which showed optic atrophy B/L. We also did a CT scan of the patient’s head, which showed cerebral atrophy with cystic encephalomalacia of the bilateral basal ganglia and bilateral parietal lobe (sequel of old infarction).

On seventh day of PICU admission, Dipika was stable and was shifted to the General ward. As she was from an orphanage home, her medication and hospital stay were provided free of charge. Later, after the third day of her stay in the General ward, Dipika’s NG tube was removed and she started to be fed by her caregiver orally. Finally, Dipika was discharged on oral medication with physiotherapy.

Suman Tamang

Age 3 Months

Suman Tamang is 3-month-old child who was admitted to Medical ward on January 31st, 2018 with the diagnosis of AGE and severe dehydration. According to his guardian, the child was well 5 days before; then he developed loose stool, 6–8 episodes, watery in consistency, non-blood mix and vomiting, 4–5 episodes per day. Suman had no history of previous hospitalization. On admission, his vital signs were monitored: temperature 98°F, respiration 34/min., and pulse rate 128/min. An IV line was opened and Ringer’s lactate 250 ml/24 hours was administered. Suman’s mother was advised to feed him a little and practice frequent breastfeeding. She was also taught the proper way of breastfeeding. She was closely monitored and also advised to maintain hygiene and kept the child warm. IO charting was maintained at hospitalization. Injectable Taxim 125 mg IV TDS was administered and Cefixime syrup (50/5) 4 ml BD for 3 days was prescribed at discharge.

Suman was discharged on the 5th of February, with a follow-up plan as needed. At discharge, his mother was advised on breastfeeding and immunization. During the follow-up visit, Suman was found to be healthy.

Ronal

Age 1

Ronal is a 1-year-old boy who was brought to the Emergency department of Kanti Children’s Hospital on the 13th of February 2018. Major complaints included cough and cold, fast breathing, and intermittent fever for 7 days.

During examination, we found Ronal’s oxygen saturation was 73% on arrival (before we administered oxygen) and his respiratory rate was 68/min. He had a history of Down’s syndrome with bilateral pseudo-membranous conjunctivitis. Hence, the patient was kept on oxygen at 4 liters via face mask, and nebulized Asthalin was administered 3 separate times. Intravenous injectable Taxim 400 mg and injectable Fluclox 400 mg were also administered. Ronal’s blood was also sent for investigation and he was referred to the Pediatric ICU.

Eva Balika

Age 7 Months

Eva Balika is a 7-month-old girl who was brought to the Emergency department of Kanti Children’s Hospital on March 7, 2018. Her chief complaints were fever for 3 days, noisy breathing, difficulty breathing, and decreased feeding. She also had been admitted to Kanti Children’s Hospital a month before.

On examination, the team observed the following:

• Temperature: 103°F
• RR: 80/min.
• Pulse: 180/min.
• Oxygen Saturation: 50/min.

In this condition, Eva was intubated and after a Pediatric ICU consultation, she was transferred to the PICU. Eva was brought from a Nepal Children’s’ Organization (NCO) orphanage, where RMF nurses help care for the children.