You are called to attend the delivery of a woman with no pre…

You are called to attend the delivery of a woman with no prenatal care. The infant is vigorous at birth, but quickly develops respiratory distress and you begin PPV. When the nurse listens for aeration, she states the heart can only be heard on the right side of the chest and aeration is poor bilaterally. You obtain the following CXR. What is your diagnosis?

A 41 week, 3.8 kg male infant is delivered via urgent c-sect…

A 41 week, 3.8 kg male infant is delivered via urgent c-section through meconium stained amniotic fluid secondary to non-reassuring fetal heart tones. He is meconium stained at delivery. Apgars are 1, 2, 5 and 7 at 1, 5, 10 and 15 minutes of life. He is admitted to the NICU intubated in 100% FiO2 with pre-ductal saturations 80-85% and post-ductal saturations 65-75%. He is on conventional ventilation with the following settings: PIP 25 PEEP 6 Rate 50 and i-time 0.3. There are copious meconium stained ETT secretions. An umbilical arterial catheter is placed and the following ABG is obtained: 7.01/70/30/16/-10. The CXR shows adequate expansion to 8-9 ribs with coarse, patchy, irregular pulmonary densities with scattered areas of consolidation. Surfactant is given with minimal improvement in oxygenation. His pre and post ductal oximeter trends remain unchanged.  A follow-up ABG is obtained 30 minutes after surfactant: 7.05/60/25/16/-10. Which of the following should you order next?