Ibuprofen

Ibuprofen is prescribed and the staff nurse begins to draw up the medication. The senior neonatal nurse insists that you wait for the paediatric consultant to arrive, as she is anxious about your management plan.

Bella’s oxygen saturations on her right hand are now 45%, right foot 44%.

The consultant subsequently arrives, who feels that baby has cyanotic congenital heart disease in light of the murmur and persistently low oxygen saturations. Ibuprofen is used to close the ductus arteriosus, typically in premature infants with a symptomatic patent ductus arteriosus (PDA). In a cyanotic baby with a duct dependent lesion, treatment with ibuprofen is potentially life threatening.

She feels that baby needs a prostaglandin infusion, and asks you to contact paediatric cardiology at the referral centre for advice and transfer. She also recommends that baby is intubated and ventilated due to the risk of respiratory failure.

You liaise with the local paediatric neonatal/cardiology centre, and explain that you are concerned about a possible duct dependent pulmonary circulation. They advise starting prostaglandin infusion at 5 nanograms/kg/minute, with a view to increasing to 10 nanograms/kg/minute if baby’s condition fails to improve.  The target oxygen saturations should be between 75-85%. The neonatal transport team are currently busy on another retrieval. They have estimated that they will arrive in around 2 hours’ time.

Your registrar offers to help by writing up the infusion and you gladly accept their help with this complex calculation. You begin drafting the transfer letter whilst the consultant and registrar discuss the baby’s condition with the family.

You are called by the neonatal nurse as baby Bella’s oxygen saturations continue to deteriorate, and have been below 45% for the last 20 minutes. The infusion has been running at 5nanograms/kg/min for the last 10 minutes. You review the prescription together. 

What should be done next?