USE OF USG AND ECHOCARDIOGRAPHY IN

EMERGENCY NEONATAL AND PICU SETUP

Dr Dinakar

Case 1-

A male neonate was born at a gestational age (GA) of 26 weeks by emergencycesarean delivery, which was performed for a non reassuring fetal heart rate(HR) with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Herequired mechanical ventilation and surfactant therapy for respiratory distresssyndrome, and an umbilical venous catheter was inserted, which was confirmed to be in the proper position on radiography.

The first week of life was complicated by ongoing pulmonary hemorrhage in context of a patent ductus arteriosus (PDA), resulting in persistent need for high-frequency ventilation. A cardiology echocardiogram did not show any other structural abnormality.

Two days later, the patient’s respiratory status worsened acutelywith fraction of inspired oxyFiO2 rising to 0.5 (baseline, 0.25–0.30), and acapillary blood gas analysis showed respiratory acidosis (pH, 7.09; partialcarbon dioxide pressure 84 mm Hg; and base deficit, –6.7).

A chest radiograph revealed substantial loss of lung volume and opacification (right hemithorax more than left; and an umbilical venous catheter below the diaphragm.

Over the next few hours, he developed relative tachycardia (HR increased to >170 beats per minute) and reduction in diastolic blood pressure to 20 to 22 mm Hg from a baseline of greater than 30 mm Hg

This condition prompted an urgent focused cardiac sonographic examination, which showed a large right-sided extracardiac fluid collection with floating echogenic material compressing the right atrium, findings consistent with pleural effusion and impending cardiac tamponade

Furthermore, focused cardiac sonography confirmed that the umbilical venous catheter tip was in the ductus venosus, but total parenteral nutrition (TPN) fluid was seen draining into the right thoracic cavity An urgent right- sided pleural tap was performed, and 70 mL of milky fluid was aspirated, which was later confirmed to be TPN fluid by laboratory assessment, resulting in immediate improvements in both respiratory and hemodynamic parameters

CASE 2 A male neonate was born at a GA of 24 weeks after spontaneous onset of

labor and required resuscitation with intubation and positive pressure ventilation. Surfactant was administered at 9 minutes of age, and Apgar scores were 1, 4, and 6 at 1, 5, and 10 minutes.

The first 2 postnatal weeks were mainly complicated with dependency on mechanical ventilation, with FiO2 requirements between 0.30 and 0.35 and intermittent episodes of apnea associated with desaturations. On day 14 of life, the neonate developed wide pulse pressures with low diastolic blood pressure (systolic/diastolic blood pressure, 48/20 mm Hg; mean, 29 mm Hg) along with a grade 2 to 3/6 systolic murmur

Clinical examination findings were positive for the presence of bounding

peripheral pulsations but otherwise reassuring. The neonate was thought to be active, well perfused, and handling well.

A chest radiograph was obtained, which showed bilateral opacities in a vascular distribution, suggestive of pulmonary over circulation

Based on a clinical diagnosis of hemodynamically important PDA, a plan to treat with Idomethacin was initiated

A neonatology fellow trained in targeted neonatal echocardiography was on clinical service and, under the remote supervision of the targeted neonatal echocardiography staff physician and approval of the attending physician, performed a scan before indomethacin administration.

which suggested the possibility of warm compensated shock

The targeted neonatal echocardiogram showed that there was no PDA, but rather, the neonate had a high left ventricular (LV) output of 430 mL/min/kg

These findings, when integrated with the clinical signs, were adjudicated to represent a low systemic vascular resistance state,

The indomethacin was withheld, and a septic workup was initiated instead. The neonate’s clinical signs resolved within 24 hours of initiating antibiotic treatment. The blood culture grew Enterococcus fecalis and coagulase-negative Staphylococcus species. The neonate was treated with a 7- day course of antibiotics, with complete recovery.

CASE3

A female neonate was born at a GA of 25 weeks at a community level 2 hospital after spontaneous onset of labor, with Apgar scores of 5, 6, and 7 at 1, 5, and 10 minutes. The neonate required invasive ventilation. On transfer to NICU, after a brief trial of nasal continuous positive airway pressure, she was reintubated because of frequent apneic episodes. A cardiologic echocardiogram requested to rule out a PDA did not show any abnormality. On day 4 of life, a peripherally inserted central catheter was inserted

Twenty-four hours later, she had sudden-onset cardiac arrest requiring cardiopulmonary resuscitation consisting of chest compressions (7 minutes total) and epinephrine (2 intravenous doses). After resuscitation, the HR stabilized to greater than 100 beats per minute, but severe oxygenation failure (FiO2 of 1.0 with peripheral capillary oxygen saturation of 85%) and systemic hypotension (mean arterial pressure, 10 mm Hg) persisted. A continuous intravenous epinephrine infusion (0.1 μg/kg/min) raised the mean arterial pressure to 22 mm Hg.

A chest radiograph did not show any change in lung fields or the size of the cardiac shadow. The peripherally inserted central catheter was noted to be deep and was pulled back by the clinical team. The neonate’s clinical condition remained unchanged for the next 30 minutes

targeted neonatal echocardiograph, which showed pericardial effusion with numerous floating echogenic foci in the pericardial sac, a collapsed right atrium, and an extremely small intracardiac volume: findings consistent with cardiac tamponade

Urgent needle pericardiocentesis was performed, and 5 mL of milky fluid (later confirmed to be TPN fluid) was drained,

Case 4- pediatric case 8year old boy presented to EMD with h/o fall from height.

child was conscious and was c/o severe pain in the back with c/o not able to move LL.

Vitals- HR- 80/min, BP- 110/70, spo2- 99%,

O/E- diagnosed to have a spinal injury with vertebral fracture. No other fractures were noted. On USG abdomen and chest revealed normal study.

Neurology and neurosurgery opinion obtained advised to immobilize the patient at the mean time

Within half an hour his BP- 80/60, HR-110/min, with hurried respiration, his orientation was slightly altered.

Immediately keeping in mind vertebral injury and spinal injury with out any blood loss and HR to be same thought of spinal shock.

USG abdomen was repeated showed IVC diameter is small and collapsibility index is very narrow <30%, and HR was 110/min, this revealed venous return is not present to the heart(pre load is less)

Started nor adrenaline infusion and supportive theraphy given.

In this case USG helped us to detect the decreased preload by looking at IVC diameter and for appropriate treatment.

Case 5 9months old presented with c/o fever and excessive crying and

cough since 4 days

O/E- temp- 100 degree, HR- 200/min, RR- 40/min, spo2- 94%.

RS- no tachypnea, no retractions, no added sounds.

Echo and usg abdomen was done

Usg abdomen- normal.

ECHO done showed no structural of functional abnormality. Tachycardia+

usg cranium done which was normal

Chest x ray AP view was taken which showed normal study.

Child was started on conservative management.

Even after 2 days child had no improvement with increasing in HR- 224/min, RR is 42- 50/min, spo2- 95% at room air. I/V/O tachycardia suspected SVT and planned to start on adenosine.

ECG was showing sinus tachycardia no signs of SVT. So we have planned for USG chest and repeat echo to rule out any other cause for tachycardia.

Echo was normal, tachycardia +

USG chest revealed left paracardiac basal segment - just beside the cardia 0.5x0.8cms consolidation.

CT chest was done which showed paracardiac basal segmental area of chronic consolidation showing early micro abscesses.

Blood c/s was done and higher antibiotics, other supportive theraphy were started. Gradually baby condition improved.

Usg chest has helped us to diagnose the condition and to give proper treatment.

Thank u