Professor’s Pearls
Section V: The Neonatal Intensive Care Unit
1 Case: A 1400-gram former 28-week preterm infant is now 31 weeks postconceptional age (PCA). She had mild respiratory distress syndrome (RDS) requiring <24 hours of ventilation and one dose of surfactant. She never received antibiotics and had no central lines of any kind. For the last 2 weeks she has been stable on a low-flow nasal cannula at FiO2 24% in an isolette, tolerating gavage feedings of fortified breast milk. On caffeine daily for apnea, she has two to four apneic episodes per day, all responsive to brief tactile stimulation. This morning the infant has a 10-mL bile-stained residual and moderate abdominal distention. Her apnea is now constant and requires vigorous stimulation. The last episode required positive pressure ventilation (PPV) with bag and mask. The nurse has increased her oxygen to 2 L/min at FiO2 40% to maintain saturation in the 88% to 90% range. On your examination, you find the infant’s perfusion to be barely adequate, with capillary refill of 4 seconds. Her blood pressure (BP) is 45/25 mm Hg with a mean arterial pressure (MAP) of 32. What are the diagnostic possibilities, and how do you work them up and treat the infant?
2 Case: This infant was born by vaginal delivery after 10 hours of rupture of membranes (ROM) at 37 weeks to a 40-year-old mother with no prenatal care in a community hospital 60 miles from your center. The obstetrician noted polyhydramnios. The newborn “choked” on his first feeding and turned blue transiently. Helicopter transport to your neonatal intensive care unit (NICU) has been requested. What questions do you have for the referring physician? What stabilization should be done before the transport team arrives? What diagnosis do you suspect? How will you prove your diagnosis?
3 Case: A 3.5-kg white male infant was born by elective cesarean delivery at 38 weeks at maternal request. He develops grunting, retractions, and an oxygen requirement soon after birth. The infant is placed in a 30% oxyhood, but within 2 hours he requires 50% oxygen to maintain saturation above 92%. Chest radiographic study shows poor expansion and a ground glass appearance to the lungs. The infant is placed on nasal continuous positive airway pressure (CPAP) +6 cm, and an umbilical artery catheter (UAC) is placed. Blood gas determination shows pH of 7.26, PaCO2of 52 mm Hg and PaO2of 55 mm Hg. About 20 minutes after this gas level is obtained, the infant’s oxygen requirement goes up to 90%, his heart rate (HR) rises to 180 beats per minute, and his blood pressure falls from a MAP of 50 to 30. He has an ashen appearance. What do you think has happened, and what should you do?
4 Case: An infant was born by spontaneous vaginal delivery (SVD) at 
weeks to a G2P1 32-year-old mother with negative laboratory test results, including group B streptococcus (GBS) (done at 36 weeks). Chromosomes and ultrasound at 22 weeks were normal. There was thick meconium in the amniotic fluid, but the infant was vigorous at birth, with Apgar scores of 7 and 9 at 1 and 5 minutes. Shortly after admission to the nursery she was noted to be cyanotic. Her respiratory rate is 70 breaths per minute, her HR is 145 beats per minute, and she is not distressed. Blood pressure is normal and equal in all four extremities. She is transferred to the NICU. What are the diagnostic possibilities? What studies should you order?
weeks to a G2P1 32-year-old mother with negative laboratory test results, including group B streptococcus (GBS) (done at 36 weeks). Chromosomes and ultrasound at 22 weeks were normal. There was thick meconium in the amniotic fluid, but the infant was vigorous at birth, with Apgar scores of 7 and 9 at 1 and 5 minutes. Shortly after admission to the nursery she was noted to be cyanotic. Her respiratory rate is 70 breaths per minute, her HR is 145 beats per minute, and she is not distressed. Blood pressure is normal and equal in all four extremities. She is transferred to the NICU. What are the diagnostic possibilities? What studies should you order?5 Case: A term male infant is now 28 hours old. His mother is anxious to go home after her uncomplicated vaginal delivery. The infant has been breastfeeding well, has passed stool twice, and is voiding adequately. When you do his discharge examination, you note that he has just vomited a large amount of bile-stained colostrum. His abdomen is firm and possibly tender; it is hard to tell because he will not stop crying. Can this infant go home? What diagnostic possibilities must be ruled out?
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