Attempt cannula

You successfully insert a new cannula on your second attempt.

Unfortunately, Nathan became very distressed during the procedure and mother also became tearful. She states that Nathan had topical anaesthetic cream for his first drip, which was not applied on this occasion. In addition, he has been taking a few sips of water and squash, and his mother questions whether a new cannula was absolutely necessary. You apologise and following on from a review of his fluid balance agree that he can continue his oral fluid challenge overnight.

In the meantime, you are called by the registrar who heard about the baby on postnatal ward with poor feeding and respiratory distress. She asks you to join her in the neonatal unit to help review the new baby. The registrar hands over that a bilirubin level was sent for the jaundiced baby by the ED nurse.

When you arrive, the registrar tells you that a baby with signs of respiratory distress such as grunting, nasal flaring, sternal recessions and tachypnoea should always be reviewed promptly, as these are indicators of a sick baby.

You review the baby in the neonatal unit. She is now 15 hours old. 

Bella Potter was born at 41 weeks gestation with a birthweight of 3.0kg. Mum booked late in her pregnancy. Her initial scan at 17 weeks was reported normal, as was a subsequent scan at 22 weeks. This was mother’s first pregnancy. She used to smoke, but denied smoking during pregnancy. She is otherwise well and had no complications during her pregnancy. 

Bella was born vaginally following spontaneous onset of labour. Mother’s waters broke 18 hours before delivery. There was a history of meconium stained liquor at delivery, which was suctioned by the midwife. Baby cried at 30 seconds and was dried and warmed, with no further resuscitation required. Apgars were scored at 8 at 1 minute, 9 at 5 minutes. 

Examination is undertaken:

Respiratory: RR 70/min, subcostal recessions. Grunting. Clear breath sounds, air entry audible. Oxygen saturations on right hand are 73%, right foot 72%. 

Cardiovascular: HR 160/min. Blue lips and peripheries noted. Left arm cuff BP 70/38, MABP 40, no difference between upper and lower limb BP. There is a grade 3 ejection systolic murmur at the upper left sternal border, which radiates across the praecordium. Her heart sounds are normal. Femoral pulses palpable bilaterally. 

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

Neurological: Active and crying, moving all 4 limbs to stimulation. Normotensive anterior fontanelle.

You place the baby in 100% oxygen. Her oxygen saturations after 10 minutes are 73%. A cannula is sited and blood tests including full blood count, renal profile, liver function, CRP, and blood culture taken 

She is started on benzylpenicillin and gentamicin and given a 20ml/kg normal saline bolus. 

Capillary blood gas:

pH 7.27
pCO₂ 7.9 kPa
pO₂ 4.5 kPa 
HCO₃ 21.6 mmol/l
BE -2.4 mmol/l
Lactate 2.2 mmol/l
Glucose 4.1 mmol/l

You request a chest x-ray:

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org.
From the case rID: 8049

The registrar calls the consultant for support.

What treatment option should be considered next?