CASE PRESENTATION PPHN

Maternal History Gravida 2; Para 0 ( 1 Abortion) Blood group : O positive. Diabetic on glugcophage Delivered live male by emergency C/section

Born 8/2/11 @ 1931 at a private Hospital by emergency c/section due to failure to progress & CPD(cephalopelvic
disproportion)

Baby X

Gestation : 37 weeks Apgars : 71 & 95 Weight : 3710 grms v

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Grunting Tachypnoea Cyanosis

AFTER BIRTH Shifted to NICU HR 145 RR 74 Sats 70% - 75% 30% incubator O2 Systolic murmur heard Cardiac Echo bidirectional flow Large PDA with

Diagnosis : PPHN
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N e xt f e w h ou r s

Baby still desaturation put IPPV

Intubated and on ventilator on

mode. Umbilical venous catheter was inserted. ABG showed respiratory acidosis.

4 H ou r s of a g e : Fluid Resuscitation:

5 ml NaHCO3 8.4% + 5 ml NACL 0.9%. Dopamine Infusion @ 2mcg/kg/min. Dobutamine infusion @ 2mcg/kg/min. Fentanyl infusion @ 1mcg/kg/hrs

Transfered to Welcare Hospital

At 6 hours of age

On arrival (1.20 am):

Cyanosis , poor perfusion and too much leak from ET tube. Blood gas - PH : 7.14 PCO2 : 72 PO2: 24 BE: -2 HCO3: 24 Therefore re-intubated and put on AC mode with higher pressures.
PIP 24/5. Rate 60 b/min. FiO2 100 %

Vitals : BP 80/33 (47) mmhg HR: 132 SpO2: 62% Temp. 36.5C Blood Gas (1 hrs after reintubation) PH: 7.31 PCO2: 44 PO2: 110 BE: -4 HCO3: 22.6

At 6 hours of age

Started on IV antibiotics after septic workup

Vancomycin, Ampicillin, Gentamycin.

FFP infusion. NACL 0.9% bolus. Dopamine started. Fentanyl infusion started.

At 11 hours of age

10 am - baby still desaturating

Pressures were increased Chest x ray done showed cardiomegaly, bilateral haziness /infilterates - Survanta given

Hypotension:
Bolus NACL 0.9%. Another FFP Infusion.

11 am Sildenafil commenced orally

At 16 hours of age
Started HFOV by 4pm: map- 18 Amp- 40 Freq-10 FiO2-100 Started muscle relaxant and sedation. Dopamine Infusion 10mcg/kg/min. Started Dobutamine 5mcg/kg/min Another FFP given. X ray done

22 hours of life

Oscillator settings increased Map: 21 Frequency: 10 Amplitude: 40 Dobutamine dose increased HFOV continued with same setting for 14 hours

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Day 2 of life
TPN and intralipid infusion started Repeat x-ray done - small opacity in RT upper zone Urinary catheter inserted ( urine output) Platelet count < 100 - PRBC transfused Elevated temperature noted Petechial and blanching rashes noted Acyclovir started Blood immunoassay for herpes sent.

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Day 3- Day 5

Continued same treatment HFOV settings decreased gradually according to baby's blood gases. Rashes subsided.

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Day 6

HFOV weaned off conventional ventilation started with AC+VG mode Urinary catheter removed urine output good Dopamine, Fentanyl infusion tapered Dobutamine discontinued.

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Day 7

Sildefanil frequency reduced. Hyperthermia present.

septic screening done. Removed central lines.

NG tube feed started. Dopamine discontinued.

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Day 8 - 10 of life.
Fentanyl infusion tapered. X ray done Rt lower zone clearing but Rt parahilar still has opacity. Sildenafil discontinued

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Day 11-12
Baby extubated and put on BCPAP with FiO2-40% Peep-5 Fentanyl discontinued. Cranial ultrasound done normal.

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Day 13- 17
BCPAP discontinued nasal cannula O2 Oral feeds given as tolerated

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Day 18 - 21
10 days of antibiotics completed 14 days of acyclovir completed Baby on full feeds Vitals stable Immunization given and hearing test passed Discharged with weight of 3620grms

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