He continues on intravenous fluids and is still ventilated. During your shift he has a low blood pressure, but this only transiently improves with two small fluid boluses of 10 ml/kg of 0.9% NaCl. A central line is sited via the right femoral vein and he is started on an inotrope (dopamine) to support his blood pressure.

Ventilation is not notably improved by the steroid, although this is to be expected as it takes 6 hours at minimum to work and has its full effect at 2 days. He remains ventilated at similar pressures and he he continues to need 30-40% oxygen.

His nurses check his blood glucose and find that it is 1.8 mmol/L, and he the rate of his glucose infusion is increased. This is a little unusual – steroids normally increase the blood glucose. However he is small and only on IV dextrose.

He is reexamined at 6 hours of age:

Respiratory: RR 30/min, no recession, some spontaneous respiration. SaO₂ 94% in 35% oxygen.
Cardiovascular: HR 165/min, cool peripherally with prolonged capillary refill. BP 70/30 mmHg, Heart sounds normal, no added sounds.

Neurological: He appears settled and comfortable on the ventilator.

Initial blood results are now back:

Hb       193 g/L

Wcc    21 x 10⁹/L

Plats    120 x 10⁹/L

Urea    3.2 mmol/L

Na       134 mmol/L

K          4.2 mmol/L

Creat   57  micromol/L

Because of his increasing instability, you discuss the situation with your consultant. She says that you have done all that is needed to support Baby Barton at this stage, but suggests starting antibiotics. She also suggests that you see if he has any risk factors for neonatal sepsis. Finally she suggests that you stop the dexamethasone as he is most likely to be septic in this situation – and his immune system will be reduced in function by the steroids.

You prescribe Benzylpenicillin and Gentamicin which is given by the nursing team. Blood cultures are taken before the antibiotics are given.

By calling the labour ward, you find that his mother had a temperature of 38.1C in labour, but she has not had any vaginal swabs.

You are thanked at the end of your shift and leave the unit.

You return the following night and are pleased to see Baby Barton has had a difficult day.

He is still ventilated, but with increased pressures and oxygen requirements. His blood pressure has been low, requiring extra fluid boluses and an increase in his dopamine.

The team have tried some feeds by nasogastric tube, but these have not been absorbed, so have been stopped. 

The blood cultures have shown a growth of Group B Streptococcus (GBS).

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After a few days you return to the NICU for another night shift and find that baby Barton is now called Dominic (Dom for short). He is now 10 days old and has done well after his difficult start. 

He is now been off the ventilator for two days and has been in supplemental oxygen at 35% altogether. He is being fed by nasogastric tube and this has been absorbed over the last day. His weight has fallen to 1.5 Kg but is now stable. He is still in the incubator and his parents are desperate to cuddle him, although he is still too unstable. His antibiotics have been stopped after seven days.

You are asked to see him as he has been having some episodes of desaturation.

He is examined:

Respiratory: RR 50/min, mild recession, equal chest movement. Some fine inspiratory crackles in all areas. No grunting. SaO₂ 92% in 55% oxygen.
Cardiovascular: HR 165/min, good capillary refill time. Bounding pulses and easy to feel femoral arteries. BP 85/30, Heart sounds normal, with a systolic murmur heard under the left clavicle.

Abdominal: Full, but soft on palpation, liver edge palpable at 4cm below costal margin, no other organs felt.

Neurological: Active and alert, moving all limbs. Anterior fontanelle soft.

He has a temperature of 36.3 C.

You request a chest radiograph and some blood tests.

Hb       135 g/L

Wcc    9.1 x 10⁹/L

Plats    410 x 10⁹/L

Urea    1.9 mmol/L

Na       137 mmol/L

K          4.7 mmol/L

Creat   39  micromol/L