LAUSR

A term male neonate is delivered by a 23-year-old primigravida woman at 40 weeks of gestation via normal vaginal delivery. The antenatal and intrapartum periods are uneventful, except for prolonged rupture of membranes of 20 hours. The neonate is placed on skin-to-skin contact with the mother and breastfeeding is initiated. At 36 hours after birth, the neonate is noted to have tachypnea, periumbilical erythema, and purulent conjunctivitis. He is transferred to the NICU with a provisional diagnosis of early-onset neonatal sepsis. Empirical antibiotics are initiated after sepsis screening and blood culture specimens are obtained and skin and conjunctival swabs performed. The neonate is noted to have oxygen saturation on pulse oximetry of 89% to 91%, improving marginally to 92% to 93% on heated humidified high-flow nasal cannula (HHFNC) with fraction of inspired oxygen (Fio2) of 0.4. There is no appreciable murmur and bilateral femoral pulses are palpable. ### Progression Over the next 24 hours the neonate developed tachycardia, with a heart rate of 168 beats/min, palpable soft hepatomegaly of 3 cm, cold peripheries, core-peripheral temperature difference of 2°C (35.6°F), and inability to oxygenate on HHFNC with Fio2 of 0.8. Chest radiography showed gross cardiomegaly (Fig 1). The peripheral pulses were bounding and noninvasive blood pressure was 52/22 mm Hg, with a …