Dr. Gaurav Agrawal

Associate Consultant
Paediatric Cardiology
BLK Heart Centre
BLK Super Speciality
Hospital, New Delhi

“I am very grateful to NICU and CTVS team for their kind support in managing the baby’s condition from admission till discharge” . - Dr. Agrawal.

THE CASE

A 27-week, 2 days pre-term male baby with extremely low birth weight was referred to BLK Super Speciality Hospital. The baby was on oxygen support and had been diagnosed with acyanotic congenital heart disease (large Patent Ductus Arteriosus). His weight was 1.2 kg at the time of admission. Before being brought to BLK Super Speciality Hospital, the baby had received a dose of surfactant for respiratory distress syndrome in another hospital. On examination, the baby was found to be suffering from Tachycardia, Tachypnea with 96% saturation on room air on oxygen support. The baby had bounding peripheral pulses. The baby was admitted in NICU and was started on nasalCPAP. Later, the baby was shifted to heated, humidified high-flow nasal cannulae. Oral furosemide and oral caffeine along with tube feeds were also started. Sepsis screen test was also done which showed negative results.

THE PROCEDURE

Bedside ECHO showed a large PDA of 3.6 mm, shunting left to right with hugely dilated LA / LV. LA-aorta ratio was 3:1. CTVS reference was taken, and after careful planning, the baby was prepared for a surgical ligation for PDA correction. Double ligation of PDA was done via left postero-lateral thoracotomy with controlled hypotension on day 28th of the baby’s life.

Post-operative echo showed no residual PDA with good LV / RV function. After the operation, the baby was continued on mechanical ventilation (PCV-VG) along with antibiotics and inotropes, which were gradually tapered off. Blood gases showed worsening respiratory acidosis, hence the baby was shifted to high frequency ventilation. Chest X-ray also showed bilateral infiltrates that were also worsening. Tracheal secretions culture were sent, and antibiotics were upgraded. Gradually, the baby improved both clinically and radiologically, and was weaned off and extubated on day 33. Tracheal secretions culture was found to be sterile, and later antibiotics were stopped.

On day 38, the baby again started showing signs of worsening respiratory distress and therefore was shifted to a non-invasive mode of ventilation (nIMV). Later, chest X-ray was taken; however, the result was unremarkable; subsequently, he was again weaned off to heated, humidified high-flow nasal cannulae on day 40. Over the course, the baby had intermittent episodes of desaturations and persistent oxygen requirement that gradually decreased over time and therefore the baby was weaned off to room air on day 57. The baby continued showing signs of improvement, and as a result, caffeine was discontinued on day 62.

THE RESULT

At the time of discharge, the baby’s weight was 1.87 kg, and he had good acceptance of palade feed. There were no further episodes of apnea and bradycardia. His follow-up checks have been promising, and the baby is doing well and gaining weight.