hello every body .. 

 

i need some help in managing preterm baby 35 weeks gestation .. and here is the story 

 

baby delivered at preterm 35 weeks , to 31 weeks old mother , there was history of leakage 3 days prior to delivery .

delivery was by c/s (variable deceleration ) . apgar 9 10 10 . b.wt2.200

 

i admit the baby to NICU .. ampicillin and claforan started 1hr later baby got apnea ,desat70..and it wasn't responded to touch , improved by manual baging . 

over the next minute observation .. baby has no spontenous breathing .. 

baby connected to M.V , UVC inserted , X RAY(  ordered normal heart shadow , no pulm.infiltrate , not HMD) . 

 

although on low setting vent . saturation 95 , heart rate 140-130.

baby has low baby and dopamine started .

 

i follow the vent. by ABG ..  and here is the problem ALL co2 is high .. 140  120   80  64  90 again .. ett tube changed . level is optimum , and i achieve 95 sat with only pip/peed 12/4 .

 

any point to help me please .. i couldn't find an explanation . 

Sepsis/meningitis very likely. you have a ventilation problem . you need to get rid of Pco2. I think you need to go up on both PIP and PEEP. what is your  vent rate?. look at the lung volume on the xray.You will need pre and postductal saturation as well. If blood pressure is low you need to give volume expansion. if this is septic shock , your pateint will need at least 3 boluses of normal saline at 20 ml/kg before starting your inotropic support. Give meningitic doses of antibiotics . keep in mind GBS or gram negative bacilli. Your antibiotic choice is good and appropriate. if the baby condition allow, do an LP. get lacate levels ,CRP(serial) and sedation. check 4 limb BP . check the femoral pulse and an echo will be helpful. hope this be of some help.

Omer Hamud

Neonatal-perinatal Medicine

Toronto.Canada

forgot to ask what is you Fio2?. Is the PIP 12 above the PEEP?

Omer Hamud

Neonatal-Perinatal Medicine

Toronto, Canada

thanks for replying :

 

Serial crp is negative , bl.p is normal .

is there any direct link between c02 and meningitis >>> i failed to get rid of co2 >> although pip/peep12/5 >> and sat.is satisfactory 95-94 

a PIP/PEEP 12/4 means that lungs are ok. If the baby breaths normally when awake I could consider a S. of Ondine, but the symptomps remember me a severe form of Spinal Muscular Atrophy.

Did you check blood ammonia?

 

Marcello De Filippo

Grosseto, Italy

Hi Aymen,

I mentioned meningitis/sepsis as the your case scenario suggest this possibility. Preterm baby, PROM for 3 days, apneas desaturation and need for inotropic support all these goes more with sepsis. But other differentials daignoses could be included i.e large bleeding in the brain , metabolic or cardiac.In this scenario , you need to provide good  antibiotics coverage for possible bugs in you institution , good respiratory and haemodynamic support.

The link between sepsis/meningitis and poor ventilation ( highish pco2)is apnea.With optimal ventilation, there should be no issue with co2 retension.My understanding is that oxygenation is not an issue here but a setting of 12/4 is really low for sick baby.I don't know ,may be you actual PIP is 16 and your PEEP is 4. but still you PEEP is minimum. Again what is the Fio2 and Rate?. what is the lung volume on xray(how many ribs do you see above the right hemidiaphragm). I undrestand your subjective information is excellent but the discussion will be more fruitful if you gave more objective finding which will quide people here).

I hope your pateint is doing well and don't forget to update us about the head ultrasound findings,ammonia level and other stuff.

Thanks.

Omer Hamud

Neonatal-Perinatal Medicine

Toronto, Canada

The problem here is ventilation , may be because of baby or ventilator , do u check up if there is autoPeep , what is Ti and I:e ratio , and I agree that your setting is low pip , also is there any PIE on x_ray , can u check it , finally may be central cause of hypoventilation