Phenomenal role of nitroglycerin in the treatment of neonata
A premature female infant was born at 26 + 3 weeks period of gestation to a multigravida following preterm premature rupture of membranes, 3 days before the delivery. As a routine protocol, the woman was given a course of antibiotics and steroid cover. The patient went into preterm labor and delivered vaginally. The birth weight was 685 g and APGAR was 6/8/8. The baby was admitted to the neonatal ICU and was put on continuous positive airway pressure (CPAP).

Within 2 h of life, the baby was intubated and was put on mechanical ventilation because of increasing FiO2 requirement on CPAP (FiO2 more than 40%). The baby was diagnosed with patent ductus arteriosus which required pharmacological closure with injection paracetamol. Cranial ultrasound was done which revealed grade-2 intraventricular hemorrhage (IVH) which resolved on conservative management.

The baby developed anemia of prematurity requiring multiple blood transfusions. Blackish discoloration developed on the left foot toes postinsertion of a peripheral intravenous line. Skin over the foot and toes was pale and cold. Skin over the lower limbs was normal. All peripheral pulses were palpable in bilateral limbs. The coagulation profile and platelet count were within normal limits.

A plastic surgeon was consulted because of digital gangrene. The intravenous catheter was removed. A gauze piece soaked with topical nitroglycerin ointment (2%) at a dose of 4 mm/kg was applied 3 times a day over the affected digits. Perfusion of the toes improved gradually with improvement in the skin color. There was a complete resolution of gangrene within 9–10 days of treatment.

During the procedure, the infant's blood pressure, heart rate, respiratory rate, and oxygen saturation were all normal. Methemoglobin levels were tested twice and found to be normal. There were no other adverse effects associated with NTG therapy. The baby made a remarkable recovery and was discharged weighing 1.8 kg on day 70 of life.

Topical NTG is a potential treatment option for neonatal peripheral gangrene. Timely initiation of treatment can result in complete recovery, thus eliminating the need for surgical debridement or amputation.