1. Case Presentation NM - PPHN
Dr Lindsay Halpern
Neonatal Consultant
City Hospital

2. Maternal / antenatal details
Mother
40 year old Black African staff nurse
No previous pregnancies
B+ve, Rubella immune, Hep B-ve, HIV-ve
Normal anomaly scan

3. Delivery Spontaneous onset of labour Meconium stained liquor
EmLSCS for suspicious CTG and foetal bradycardia
31/1/14 05:28
40+1
3.366kg

4. Resuscitation Weak cry, good respiratory effort
Transferred to resuscitaire at 20 seconds, cry improved, dried and wrapped
Gurgling heard, lots of meconium stained mucus suctioned and cry improved
Given to Dad at 2 mins 30 sec
Reassessed at 5 mins in Dad’s arms – floppy – transferred back to resuscitaire
Monitoring commenced, HR 109, sats 33% in air
Given jaw thrust, PEEP, FiO2 up to 100%
No meconium seen at or beyond cords
Transferred to NNU on PEEP, FiO2 60% with sats 95%

5. Resuscitation Apgars 91,35,710 Cord gases
Arterial pH 7.18, CO2 8.54, HCO3 23.6, BE -5.7
Venous pH 7.27, CO2 6.25, HCO3 20.9, BE-6.1

6. Respiratory Commenced on nCPAP 6cm FiO260%
Initial cap gas (1 hr of age) pH 7.09, CO , O BE -7.1, HCO3 24.7
Art gas after 30 mins pH 7.14, CO2 9.97, O2 7.16, BE-5.9, HCO3 25
Intubated at 2 hours
SIMV 18/5, R60, Ti 0.35, FiO2 25%

8. Respiratory Continued
Post intubation gas pH7.36, CO2 4.85, O2 6.56, BE-5, HCO3 19.8
R 50
FiO2 increased to 100% over next 12 hours (16 hours of age), Pip gradually increased to 28 at 13 hours of age, R 60, Ti 0.4
Sedated and paralysed
Nitric commenced at 9 hours of age at 20 ppm, 24/6, R50, FiO2 85%, OI 9
Surfactant 200mg/kg at 12 hours of age
OI increased – 23 – 32
Nitric increased to 30ppm at 13 hours of age

9. CVS Admission BP 58/24 (34); Commenced 60 mls/kg/day
10% difference in pre and post ductal sats and MBP 50
Dopamine commenced at 9 hours of age mcg/kg/min at 12 hours of age
Dobutamine commenced at 13 hours of age – mcg/kg/min at 15 hours of age
Received 10mls/kg 0.9% saline at 13 hours of age
Adrenaline and hydrocortisone commenced at 16 hours of age
MBP 44-54
Echo – confirmed PPHN, severe TR, estimated PAP 55, Bidirectional shunt at PFO and PDA

10. Infection Commenced Benzylpenicillin and Gentamicin
CRP<5, WCC 16.3, Neut 9.76, plt 339
Blood cultures negative

11. GI
NBM, iv fluids
Blood glucose 5-8

12. Neurology
? Abnormal leg movement
? Abnormal posture
Normal CUSS

13. Consideration for ECMO
Discussed with ECMO team
No bed at Leicester
ECMO team collecting a baby from Brighton
ECMO team contacted KIDS team
For transfer to BCH for ECMO
SIMV 32/7, R60, Ti0.6, FiO2 100%, Nitric 35
Morphine 20, Atracuronium 660, Dobutamine 20, Dopamine 20, Adrenaline, Hydrocortisone
pH7.25, CO2 6.13, O2 6.24, BE-7.5, HCO3 19.6
MBP 54, sats 94%
NTS present from about 11 until 16 hours of age
KIDS team left at 17 hours of age

14. At BCH
5 cardiac arrests – requiring chest compressions and adrenaline.
Difficult to ventilate. Received HFOV and nitric, further dose of surfactant, Converted to conventional ventilation after 48 hours. Extubated on day 5.
Required dobamine, dobutamine, adrenaline, noradrenaline, hydrocortisone
Cooled for 24 hours post arrest

15. At City Transferred back day 5. 0.5l np O2, s/v air day 12
Establishing enteral feeds, full enteral feeds day 9
Good suck, normal neurological examination, no seizures
Normal MRI
Discharged home day 16
Well at 8 week follow up