Case 16: Postoperative Respiratory Complications in a Neonate

Abstract

A 3-day-old boy is scheduled for repair of a tracheoesophageal fistula. No other abnormalities are noted. Anesthesia is induced with sevoflurane, and suxamethonium is given to place an endotracheal tube (ETT) (3 mm) in the trachea. Anesthesia is maintained with 70 % nitrous oxide in oxygen and halothane. Vecuronium is given as a muscle relaxant. A thoracic epidural is inserted via the caudal canal to approximately T6 [1]. During the operation, the catheter is infused with bupivacaine 0.125 % at a rate of 0.5 ml per hour. The operation is completed uneventfully, and the ETT is removed from the baby’s trachea. During the first 24 h, the baby’s vital signs are stable. The surgeon is keen to remove the epidural catheter and start the child on oral/rectal nonsteroidal anti-inflammatory drugs (NSAIDs). You agree but leave the epidural catheter in situ. After 2 h, the respiratory rate increases from 45 to 55 breaths per minute. The baby’s saturation decreases from 95 % to 90 %. The inspired oxygen is increased to 30 % and more rectal analgesic is administered. Continuous positive airway pressure (CPAP) (5 cm H₂O) is given, and some improvement is seen in the vital signs. You feel happier about the baby until the nurse brings you a chest X-ray of the patient taken 5 min previously. This shows a right middle and lower lobe collapse. The oxygen saturation is now 88 %.