INTENSIVE CARE

After dexamethasone was given for one day, an ECHO on
showed: improved mild to moderate right sided chamber
dilation, and normal right ventricular systolic function, ongoing.
The child had significant pulmonary improvement with
dexamethasone. The dexamthasone was weaned by 0.1 mg/kg/
per day from 0.4 to 0.1 mg/kg/ per day over three days. At six
days of age HFOV settings were: (MAP: 15 cmH2O, Amplitude:
34, Hz: 9, Flow: 20 Lpm, Inspiratory time 33% and FiO2 0.34).
The iNO was weaned from 20 ppm to 18 ppm while PaO2
remained greater than 90 mmHg. The goal was to keep PaO2 60
to 100 mmHg, as the child was very labile.
iNO had been weaned to 4 ppm remained at 4 ppm despite an
increase in oxygen requirement. pCO2 on serial cbg’s showed
a compensated respiratory acidosis at 57 to 55 mmHg post
extubation.
Repeat echocardiogram was done after the iNO was initially
weaned. This showed improvement in pulmonary arterial
pressures. Pulmonary artery pressure improved and right sided
chamber dilatation decreased.
At seven days of age, the infant transitioned back to conventional
ventilation (SIMV mode, respiratory rate of 45 breaths per
minute, PIP: 25 cmH2O, PEEP: 7 cmH2O, I time: 0.38 seconds,
10 cmH2O of pressure support and FiO2 0.35). Nebulizers via the
aerogen was restarted every six hours. Pulmicort SVN as added
in BID 0.5 mg. Nitric Oxide was then weaned by 5ppm every six
hours until reaching a dose of 5 ppm.
At eight days of age, the infant met the NICU’s extubation
guideline: FiO2 ≤35%, rate ≤ 25 bpm, PIP ≤ 18 cmH2O; pH ≥ 7.20,
PCO2 ≤ 55 mmHg; No paralytic or excessive sedation; Caffeine if
GA ≤30 wks; Post extubation support for 72 hrs.
DOL 9: Post Extubation: Persistent mild pulmonary hyperinflation. Persistent
coarse interstitial opacities throughout the lungs with subsegmental
atelectasis in the right upper lobe and left lower lobe, consistent with known
history of meconium aspiration.
Nasal SIMV settings were increased to a pressure of 24 cmH2O
and PEEP of 7 cmH2O due to a FiO2 requirement. However,
chest X-ray findings showed over-inflation and subsegmental
atelectatis bilaterally.
From 9 to 12 days of age, the iNO was weaned by 1 ppm every
day. The child remained on nasal SIMV settingds around 0.40
FiO2 and cbg showed: 7.387/pCO2 52 mmHg/31 mmol/L/4.8 base
excess).
The infant transitioned to nasal CPAP. (CBG: 7.369/pCO2 60
mmHg/34 mmol/L/6.9 base excess).
DOL 9: Pre extubation: Stable position of ETT and UVC. Persistent pulmonary
hyperinflation. Persistent subsegmental atelectasis in the right upper lobe.
Persistent streaky interstitial opacities consistent with history of meconium
aspiration. Relative increased lucency in the right lateral chest, which may be
secondary to projection however underlying pneumothorax cannot be
definitively excluded.
The infant was extubated from SIMV 20 bpm, PIP: 18 cmH2O,
PEEP: 6 cmH2O, 0.38 seconds I time, pressure support of
10 cmH2O and 0.30 FiO2 to Nasal SIMV rate of 40, PIP 22
cmH2O, PEEP 6 cmH2O, I time- 0.5 seconds, and 0.40 FiO2 and
4 ppm iNO. Nasal SIMV was provided via the RAM cannula.
DOL 23: No significant change in course central opacities, likely atelectasis.
30 neonatal INTENSIVE CARE Vol. 29 No. 4 • Fall 2016