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December 2008 Neonatal Cardiac Emergencies: Management Strategies in THIS ISSUE by P NEONATOLOGY TODAY News and Information for BC/BE Neonatologists and Perinatologists Volume 3 / Issue 12 December 2008 Neonatal Cardiac Emergencies: Management Strategies IN THIS ISSUE By P. Syamasundar Rao, MD base status and treatment of metabolic aci- dosis with sodium bicarbonate (NaHCO3) Neonatal Cardiac and management of respiratory acidosis Emergencies: Management Strategies INTRODUCTION with suction, intubation, assisted ventilation by P. Syamasundar Rao, MD as deemed necessary, are important and Page 1 Emergencies of life-threatening nature involv- should be diligently undertaken in all pa- ing the cardiovascular system in the neonate tients. In most cyanotic heart defects FIO2 of Perspectives on Safety: are many and complex. Successful man- no more than 40% is necessary because of Identifying Adverse Events agement depends upon prompt and accurate fixed intracardiac shunting. In certain cya- Not Present on Admission: diagnosis of the problem in order to institute notic heart defects (CHDs), for example, Can We Do It?. Hypoplastic Left Heart Syndrome, 100% by James M. Naessens, ScD appropriate therapeutic measures and refer- FIO2 may be detrimental to the patient by Page 8 ral to a specialized treatment center, if nec- essary. These situations may manifest increasing the pulmonary flow at the ex- themselves as severe cyanosis, heart fail- pense of systemic perfusion. Specific meas- DEPARTMENTS ure, lethargy and lack of spontaneous ures depend on the diagnosis and will dis- movement or arrhythmia (Table I). The pur- cussed here-under. Medical News, Products and pose of this presentation is to draw attention Information to cardiac emergencies in neonates and to NEONATAL CYANOSIS Page 6 discuss their management. Cyanosis is an important manifestation of NEONATOLOGY TODAY GENERAL MANAGEMENT severe CHD in the neonate, as has been alluded to by a number of cardiologists [1-5]. Editorial and Subscription Offices 16 Cove Rd, Ste. 200 During the process of identification and Central cyanosis is manifested by bluish Westerly, RI 02891 USA work-up, prevention of hypothermia, mainte- discoloration of mucous membranes and is www.NeonatologyToday.net nance of neutral thermal environment, moni- generally more difficult to identify in the toring for and prompt treatment of hypogly- neonate than in older subjects. The ready availability of pulse oxymeters makes the Neonatology Today (NT) is a cemia and hypocalcaemia, monitoring acid- monthly newsletter for BC/BE neo- confirmation of cyanosis easier than obtain- natologists and perinatologists that ing blood gas analysis. The methods to dis- provides timely news and informa- tinguish cardiac from non-cardiac cyanosis tion regarding the care of newborns Table I. List of Cardiac Emergencies in and the diagnosis and treatment of and steps used to formulate a cardiac diag- premature and/or sick infants. the Neonate nosis are discussed elsewhere [5] and are © 2008 by Neonatology Today beyond the scope of this presentation, ex- ISSN: 1932-7129 (print); 1932- 1. Cyanosis in the newborn cept to state that evaluation of pulmonary 7137 (online). Published monthly. 2. Congestive heart failure blood flow by chest X-ray is useful in cate- All rights reserved. 3. Lethargy and lack of spontaneous gorization of CHD babies, especially prior to Statements or opinions expressed in movement echocardiographic and/or angiographic stud- Neonatology Today reflect the views ies. of the authors and sponsors, and 4. Arrhythmias are not necessarily the views of Neonatology Today. NEO The Conference Feb. 26 - Mar. 1, 2009 Pre-conference CQI day - Feb. 25 Do you or your colleagues have interesting research results, Disney Yacht and observations, human interest stories, reports of meetings, etc. Beach Club Resorts Lake Buena Vista, FL USA that you would like to share with the neonatology community? www.NeoConference.com If so, submit a brief summary of your proposed article to Neonatology Today at: [email protected] The final manuscript may be between 400-3,500 words, contain pictures, Recruitment Ads on Pages: graphs, charts and tables. 2, 11 www.NeonatologyToday.net NEONATOLOGY POSITIONS AVAILABLE NATIONWIDE MEDICAL GROUP Pediatrix Medical Group offers physicians the best of both worlds: the clinical autonomy and atmosphere of a local private practice coupled with the opportunities, administrative relief and clinical support that come from an affiliation with a nationwide network. Pediatrix offers physicians: I Professional liability insurance I Comprehensive health/life benefits I Competitive salaries I Relocation assistance I CME allowance I Clinical research opportunities Visit our Web site at www.pediatrix.com/careers to learn more. We currently have openings in the following locations: ARIZONA GEORGIA OKLAHOMA Phoenix Atlanta Tulsa Tucson Macon Savannah SOUTH CAROLINA CALIFORNIA Columbia Fountain Valley KANSAS Florence Lancaster Topeka Greenville Oxnard Wichita Spartanburg Palm Springs Pasadena LOUISIANA TENNESSEE West Covina Baton Rouge Chattanooga Memphis What’s new on COLORADO NEVADA Denver Las Vegas TEXAS campus? Reno El Paso FLORIDA Houston Floater NEW YORK San Antonio Visit the Pediatrix Orlando Elmira Victoria Pensacola University campus at Tampa Bay NORTH CAROLINA WASHINGTON www.pediatrixu.com Concord Seattle to learn more about our OHIO PUERTO RICO continuing education Columbus activities. Recent Dayton Grand Rounds include: Locum Tenens opportunities also available in many locations. An Equal Opportunity Employer • Considering GE Reflux Disease (GERD) 800.243.3839, x 6512 in the Neonate 800.765.9859 fax MEDICAL GROUP NEONATOLOGY TODAY 3 December 2008 Decreased Pulmonary Vascular Markings If the cause of cyanosis is secondary to pulmonary atresia with intact ventricular septum or critical pulmonary stenosis, transcatheter ra- Neonates with severe cyanosis and decreased pulmonary diofrequency perforation of the atretic pulmonary valve [8,13-15] or bal- vascular markings on chest roentgenogram are likely to have loon pulmonary valvuloplasty [16-20], respectively may be undertaken. severe right ventricular outflow tract obstruction and may have ductal dependant pulmonary circulation (Table II-A). Increased Pulmonary Vascular Markings The ductus may be kept open by an infusion of prostaglandin E1 (PGE1). Various cardiac defects with ductal-dependent Cyanotic neonates with increased pulmonary flow may have transpo- pulmonary blood flow in which prostaglandin is useful are sition of the great arteries, Hypoplastic Left Heart Syndrome, coarcta- listed in Table II-A. The current recommendations are for in- tion of the aorta and multiple left-to-right shunts. fusion of PGE1 at a dose of 0.05 to 0.1 mcg/kg/min intrave- nously. Although PGE1 has been used in infants beyond the In infants with severe cyanosis and increased pulmonary blood flow first month of life, it is most likely to be effective the earlier in on chest X-ray, the cause of cyanosis is likely to be transposition of life it is begun. It appears that a small ductus can be dilated, the great arteries. Initially starting PGE1 to open the ductus to improve but an already closed ductus may be difficult to reopen. Side mixing may be undertaken followed by balloon atrial septostomy effects include apnea (10%), elevation of temperature (10%), [21,22]. Within the next few days arterial switch procedure [23] may be muscular twitching, and severe flushing. The side effects performed. have not posed substantial management problems; however, the infant should be watched for apnea. Once the O2 satura- Infants with mild cyanosis and increased pulmonary blood flow on chest tions improve, the PGE1 dose should be weaned down to X-ray are likely to have signs of congestive heart failure. The treatment 0.025 to 0.03 mcg/Kg/min; this is particularly useful in pre- of congestive heart failure, including administration of inotropic agents, venting apnea and need for endotrachial ventilation. The ma- diuretics and after-load reducing agents is similar to that of older chil- jor benefit of prostaglandin use lies in its keeping infants in a dren [24] and will not be discussed, except to state that the neonatal reasonable condition while the infant is being transferred to a myocardial development is incomplete [25], and that the myocardial tertiary care institution. Also, well-planned catheterization and response to pre-load and after-load manipulations and inotropic agents angiography, as well as palliative or corrective surgery, can is suboptimal. In conditions in which perfusion to the body (Table II-B) is be performed with relative safety because of higher PO2 and ductal dependent, administration of PGE1 is necessary. The dosage and correction of metabolic acidosis. No more than 40% of hu- administration of PGE1 are the same as described above. Once the midified oxygen is necessary in infants with cyanotic congeni- infant is stabilized, the lesions require surgical intervention. tal heart disease since they have fixed intracardiac right to left shunt. Once the diagnosis is established by echo-Doppler Pulmonary Venous Congestion and/or cardiac catheterization studies, a permanent way to provide pulmonary blood flow should be considered. In pa- Majority of patients with severe pulmonary venous congestion on tients whose cardiac defect could not be corrected in the chest X-ray are likely to have infra-diaphragmatic type total anomalous neonatal period, a Blalock-Taussig shunt [6] is performed; pulmonary venous connection and require emergent surgical correc- most
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