Surfactant

Bella is intubated and the correct position of the endotracheal tube is confirmed. A treatment dose of surfactant is given via the ETT tube.

You review the baby after 10 minutes.

Respiratory: Ventilated on 100% oxygen. Good chest wall movement, equal air entry on auscultation. Oxygen saturations on right hand are 55%, right foot 54%.

Cardiovascular: HR 170/min. Blue lips and peripheries. Harsh grade IV systolic murmur, heart sounds are normal. Femoral pulses palpable bilaterally. 

Abdomen: Not distended, soft on palpation. 1cm liver edge palpable below costal margin.

Neurological: Sedated on morphine infusion.

The consultant subsequently arrives, and is worried that baby has cyanotic congenital heart disease in light of the murmur and persistently low oxygen saturations. Surfactant is used in preterm infants with respiratory distress syndrome, and in term infants with meconium aspiration syndrome. Meconium aspiration is unlikely to be the cause of Bella’s hypoxia due to the presence of the murmur and persistent hypoxia.

She feels that baby needs a prostaglandin infusion, and advises contacting paediatric cardiology at the referral centre for advice and transfer. 

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 50% 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?