Oxygen

Love is like oxygen. You get too much, you get too high. Not enough and you're gonna die. – Andrew Scott and Trevor Griffen The case A 2-day-old, 26-week, 740-g male infant was admitted for repair of tracheoesophageal fistula (TEF). The pregnancy was the product of a rape and was complicated by polyhydramnios, herpes simplex virus infection, preeclampsia, and ultrasound suggestion of fetal esophageal atresia and absence of the corpus callosum. The infant was delivered by cesarean section due to maternal preeclampsia. The infant was limp and required bag-mask ventilation, then endotracheal intubation and a brief period of chest compressions for bradycardia. Apgars were 1, 1, 5. Chest X-ray showed an enteric tube at the level of the clavicles, air in the stomach and intestines, and bilateral diffuse granularity of the lung fields. An echocardiogram showed patent foramen ovale (PFO), a small pulmonary artery and pulmonary artery hypertension, good left and right ventricular function, and otherwise normal cardiac structure. The child also had hypospadias and hydronephrosis. The infant developed worsening lung compliance and was given surfactant and placed on an oscillator. You are consulted to take this child to the operating room for thoracotomy, ligation of TEF, and possible repair of the esophageal atresia; the team feels that the child is getting worse and that repair of the TEF might help improve oxygenation and ventilation. You think to yourself, “Yeah, if the baby survives the operation!” To make matters worse, it is 10 o'clock at night.