Premature baby, 25 weeks gestation, was referred to my service immediately only after he was delivered, as the mother arrived in the hospital in active labor already. With all my might, I drove hastily to attend to him as the first few minutes is very critical for baby’s survival – their breathing, their temperature regulation more importantly. Gladly, their referral was, baby is on 100% oxygen saturation with low flow oxygen via his nasal catheter.
Arriving at the NICU, I immediately attended to his needs. His x-ray showed a severe form of surfactant deficiency. Talked to the dad and explained the condition of the baby. He needed surfactant badly. Unfortunately, resources are limited, he cannot provide it as he recently resigned from work and no one else can provide support that very instant. Baby had to make do with mere ventilatory support… but with risks…
The first 24 hours of preterm was essentially unremarkable, he was stable. In fact, on the 25th to 30th hour of life, I began weaning off the ventilatory support. (amazing) But on the 36th hour of life, he started deteriorating. Ventilatory support had to be increased to the point of a peak inspiratory pressure at 40 cmH20. This was the only setting that he became stable… (but with a PRIZE!) When I noticed that he was stable, I decided to go home and have my dinner. But upon arriving at home, I got a distress call that his heart rate suddenly fell. It was gut-wrenching feeling… I immediately ordered x-ray while I rushed back to the hospital (a 10 minute drive without traffic for an amateur driver like me). Lo and behold, he had pneumothorax on both lungs! Not just pneumothorax, but TENSION pneumothorax. There was a point of rupture somewhere along the baby’s lungs where air escaped from into the chest cavity. The air leak kept on increasing volume, on an enclosed space, thus compressing the lungs like a tin can, as well as the heart. This compression disables the heart to pump blood effectively thus causing decrease in the strength of pulses, blood pressure, faint/distant heart tones.
(Not the actual patient. Photo courtesy of http://images.mitrasites.com/wallpaper/pneumothorax.html)
I immediately inserted needle onto the chest of the baby, both sides, after proper preparation and giving baby analgesics, to drain the air from the chest, to stop compressing on the lungs and heart. But… it was not enough. There was continuous exodus of air, and the baby’s heart beat and oxygenation has not improved significantly; I thought that the air leak must be so large that’s causing continuous egress of air.
Needle thoracentesis. (Image courtesy of http://gtranatomy.blogspot.com/2011/04/blogation-numero-cuatro.html). Of course, this was done with baby lying supine though.
Chest tube thoracostomy. (Image courtesy of http://www.medicalexhibits.com/medical_exhibits.php?exhibit=05001_02X&query=chest%20tube%20placement%20technique%20placing%20thoracostomy%20tube)
I called in the pediatric surgeon to insert a bigger tube to help drain the chest of air. This was indeed a pulse-raising scenario. Had I a heart condition, I could already have chest pain or maybe heart attack at that instant, that was how tension-filled the NICU was at that moment.
But… after all our concerted, heroic efforts to save the baby, he continued to deteriorate. We resuscitated him, but he didn’t make it. When the parents came in, the mother hugged me, crying. It was heart-breaking scenario, as baby was their first…
When all things were settled, I finally bid them everyone. I went to an open fast-food chain to buy myself a dinner. It was midnight. Then I drove back home, to rest… because in a few hours time, I have a scheduled CS delivery to attend to.