1. Rescue High Frequency Ventilation in Pulmonary Hemorrhage in an Extremely Low Birth Weight Hypothermic Infant
authors: Marta Simon1, Manuela C. Cucerea1, Zsuzsanna Gall1, Monika Rusneac2, Luminita Zahiu2, Carmen Movileanu2, Raluca Marian1, Laura Suciu1
1. Pediatrics 4, University of Medicine and Pharmacy Targu -Mures, Targu-Mures, Romania. 2. Mures County Emergency Hospital, Targu-Mures, Romania
INSTITUTIONS:
INTRODUCTION:
Extremly low birth weight (ELBW) is one of the main reason for neonatal intensive care. ELBW infants are at risc for developing respiratory distress syndrome (RDS), hypothermia, intraventricular hemorrhage and symptomatic persistant ductus arteriosus. Improper care at birth may worsen the symptomatology and the outcome of these prematures. Intensive care involves stabilizing the infant, optimizing ventilation and oxygenation, and treating the underlying pathology, using the less invasive methods available in order to prevent long term complications
Pulmonary hemorrhage is an acute, often times catastrophic event characterized by discharge of fresh blood or bloody fluid from the upper respiratory tract or the endotracheal tube with a high mortality rate.
Risk factors include: prematurity, RDS, hypothermia, PDA, infections, coagulopathies, surfactant replacement therapy, etc.
CASE PRESENTATION:
B.L. an ELBW 26 weeker premature baby girl, weithing 660 g, L: 31cm, CP: 23cm at birth, born at home on and had been transfered to our NICU after 10 hours of life with symptoms of RDS.
Status at admittance: cyanosis, Sat O2: 37%, severe hypothermia: 32grd Celsius, HR: /min, UVC present, she received glucose infusion during transportation, blood sugar: 210mg%.
After immediat resuscitation: PPV with bag and mask, HR increased >100/min, SatO2 stabilized at 90%, SiPAP was initiated via InfantFlow, iv fluids for normalizing acidobase and hydroelectrolitic status, and slow rewarming.
She initially was stable on BiPAP, but after 6 hoursSat O2 fallen to %, HR to 80/min, during suctioning the mouth discharge of fresh blood was observed, with rapid deterioration of the infant’s status.
ET tube was inserted and blood was aspirated from the trachea. Epinephrine was given on the ET tube, and HFOV was initiated.
Ventilatory parameters: FiO2 100%, MAP 11 cmH2O, FR 8.5 Hz, A 30 cm H2O
FFP was infused, later platelet transfusion was needed for correction of thrombocytopenia
Hypotension needed dopamine infusion (rate: 5mcg/kg/min)
She received surfactant replacement after stabilizing and ceasing of pulmonary hemorrhage
HFOV was continued for 15 days, FR could be increased after 2 days to10Hz, and MAP decreased to 9 cmH2O, FiO2 was reduced as soon as SatO2 were stable on 90%
After extubation further 28 days she received NCPAP
Other treatments:
Antibiotics: meropenem and colistin for positive cultures from the tracheal aspiration with Klebsiella Pneumoniae
Fluconazol for candidiasis prophilaxis
Repeted surfactant replacement (2 doses)
Caffeine citrate
Dexamethasone after extubation for mild form of BPD
Outcome:
The baby was discharged on , with 2700g, L: 47cm; CP: 34 cm, at a corrected age of 44 weeks.
ROP screening: grd I ROP with spontaneous resolution
Audio screening: Pass
Transfontanellar US: normal
Neurodevelopment: adequate for 44 weeks
Nutricion: post discharge formula
Head US showed grd II HIV at admittance
Chest X-ray showed reduced lung volume, lung parenchyma with fine granular pattern, and presence of air bronchograms
Discussions:
More than 1 known risk factors were present in our case: a 26 weeker ELBW, with RDS and possibly perinatal infection, who suffered hypothermia and developed intrainfectious thrombocytopenia.
Hypothermia worsened the acid-base status, respiratory functions and left-to right shunting through PDA, leading to pulmonary hemorrhage.
Increasing intrapulmonary pressure and expension of lungs by using lower frequency parameters of HFOV the shunt could be influenced in order to cease the hemorrhage. Despite relatively higher initial MAP severe pulmonary fibrosis did not occur, due to a relatively constant pressure in the airways, that is lower than usually used parameters in conventional ventilation
Conclusions:
High frequency oscillatory ventilation should be the elective ventilation mode in ELBW infants with RDS and/or pulmonary hemorrhage in order to get prompt respons and reduce major complications
References
4. S.Y.Ko, Y.S.Chang, W.S.Park: Massive pulmonary hemorrhage in newborn infants successfully treated with high frequency oscillatory ventilation. J Koren Med Sci 1998; 13:495-9
3. AlKharfy T M. High-Frequency Ventilation in the Management of Very-Low-Birth-Weight Infants with Pulmonary Hemorrhage. Amer J Perinatol 2004; 21(1): DOI: /s
2. Cloherty, J., Eichenwald, E, Hansen AR, Stark, A.R, (Eds.). (2012). Manual of neonatal care (7th ed.). Philadelphia: Lippincott-Williams & Wilkins.
1. Knobel R, Diane Holditch-Davis. Thermoregulation and Heat Loss Prevention After Birth and During Neonatal Intensive-Care Unit Stabilization of Extremely Low-Birthweight Infants. JOGNN May/June (3): 280–287.DOI: /j x