I would like to know what the forum members feel regarding these two scenario: 

1. Term infant with signs of PPHN, CXR: dark lung fields ( idiopathic/primary PPHN), well expanded, on HFOV, ECHO: PPHN. Preductal sats in the 70s-80s. Do you give surfactant or go straight to iNO? There is expert opinion that giving surfactant in these situations worsen the clinical situation. Please share your experience/available literature. 

2. Term infant with GBS positive mother. She was started on GBS prophylaxis as per ACOG guidelines when she was in labor and she gets one dose and miss subsequent two doses, prolonged labor. Last dose of antibiotic was given 8-12h ago. Baby is well on exam, no chorioamnionitis diagnosis by OB. Mother request early discharge at 24h. Do yo consider this as adequate IAP and discharge baby or watch baby for 48h as per AAP guidelines? Also, another case of mother receiving AIP 3h prior to delivery and she request discharge at 24h. Please share your practice. Thank you

For #1 - from a pathophys view (decreasing pulm vascular resistance is the key goal) so iNO would certainly be my option.

For #2 - given a completely well infant at 24h, we would be OK with discharge at 24h.

2# if mother received B. Penicillin or Ampicillin or cefazolin more than 4 hes before delivery is considered adequate prophylaxis. 
observation can be enough for 24 hrs if parents are well educated regarding warning signs and have immediate access to clinical services.

1# first of all is ensure adequate recruitment with adequate ventilation then consider surfactant if fio2 requirements still high.

2# to check how much is pulmonary pressure and cardiac function before starting iNO.

if adequate myocardial function, can start iNo. If not don’t give.

start inotropes to increase your Systemic pressure above pulmonary pressure.

adequate sedation and pain management and minimal handling 

 

For #1, you answered yourself dark lung fields, so no RDS, hence no surfactant, looks like vascular phenomena rather than parenchymal as your scenario. Treatment lung protective strategy, and pulmonary vasodilation.

for #2, adequate coverage, can be discharge with follow up

I will just go for number one.  

NO surfactant.  You do not have a CXR indicative of RDS.  You have an infant with existing pulmonary hypertension, and clogging the airway with unneeded surfactant will only worsen the disease process.  

Just as you would not bolus a child with saline to treat hypoglycemia, do not give the wrong drug to treat PPHN.

9 hours ago, Alaa said:

2# if mother received B. Penicillin or Ampicillin or cefazolin more than 4 hes before delivery is considered adequate prophylaxis. 
observation can be enough for 24 hrs if parents are well educated regarding warning signs and have immediate access to clinical services.

1# first of all is ensure adequate recruitment with adequate ventilation then consider surfactant if fio2 requirements still high.

2# to check how much is pulmonary pressure and cardiac function before starting iNO.

if adequate myocardial function, can start iNo. If not don’t give.

start inotropes to increase your Systemic pressure above pulmonary pressure.

adequate sedation and pain management and minimal handling 

 

Thank you

for scenario 1 I would say iNO and no surfactant. The description of CXR does not imply RDS and or secondary surfactant deactivation disease processes. Therefore surfactant may not help.

1) Surfactant in a PPHN situation will give a transient endogen NO-release in the lungs improving SpO2 in the short term. For the long term it is better to start iNO.

1) Surfactant might be indicated in a situation of meconium aspiration syndrome driven PPHN.

1) Regardless, if oxygen index is above 20 (30) = start iNO.