INTENSIVE CARE
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On day of life 23, the infant transitioned to 1/8 Lpm of 100%<br />
oxygen via nasal cannula. All nebulizers were discontinued. At 31<br />
days of age, the infant transitioned to room air. Capillary blood<br />
gas showed: 7.344/pCO2 51 mmHg/27 mmol/L. Echocardiogram<br />
was normal, with resolution of PPHN and normal contractility.<br />
Discussion<br />
A 40 4/7 week infant was admitted for meconium aspiration<br />
syndrome with severe pulmonary hypertension, which has at<br />
discharge. The infant’s hospital course was complicated by eight<br />
days on endotracheal tube ventilation, 15 days of NIPPV, 5 days<br />
of NCPAP, and 8 days of straight flow nasal cannula. The hild<br />
had 11 days of iNO, and one week of systemic steroids. He had<br />
a course of IV antibiotics for MAS and required IV sedation. Off<br />
of the sedation the infant experienced fussiness and went home<br />
on acetamiophen. Prior to discharge, the infant was able to be<br />
weaned to room air, tolerated all feeding orally, and had good<br />
weight gain.<br />
The parents elected not to have brain MRI because the vEEG<br />
was normal. Head ultrasound did reveal bilateral grade 1 IVH.<br />
In review of this case, the child tolerated iNO delivered by RAM<br />
cannula. However, following extubation the oxygen requirement<br />
increased from 0.30 to 0.40. Although the chest X-ray revealed<br />
areas of hyperinflation, the SIMV had to be increased. It may<br />
have been beneficial to increase the iNO dose at the time of<br />
extubation.<br />
Furthermore, did increasing positive pressure via a RAM cannula<br />
could cause more irritation, and increased effort for exhalation.<br />
Meconium will inactivate a newborn’s endogenous surfactant<br />
and decrease levels of surfactant proteins A and B. 1 Causing a<br />
severe inflammatory response. MAS impacts alveolar circulation.<br />
This was a severe case of both inflammation and circulation<br />
impairment. 3<br />
Nair, 4 et al reported a case PPHN with mild respiratory distress<br />
responding to nasasl cannula iNO. Our case represents severe<br />
MAS with severe PPHN, with on going iNO requirement after<br />
extubation. The child tolerated iNO by RAM cannula.<br />
References<br />
1. Donn, Steven M. Manual of Neonatal Respiratory Care. Third<br />
Edition. 2012.<br />
2. Fanaroff, Avroty A. and Fanaroff, Jonathon M. Care of the<br />
High-Risk Neonate. 6th Edition. 2013.<br />
3. Lindenskov PH, Castellheim A, Saugstad OD, Mollnes TE.<br />
Meconium aspiration syndrome: possible pathophysiological<br />
mechanisms and future potential therapies. Neonatology<br />
2015;107(3):225-30.<br />
4. Nair et al, Successful Treatment of a Neonate with Idiopathic<br />
Persistent Pulmonary Hypertension. AJP Rep. 2012<br />
neonatal <strong>INTENSIVE</strong> <strong>CARE</strong> Vol. 29 No. 4 • Fall 2016 31