Life Saving Interventions on Newborn Basis

INTRODUCTION

Khadiza o5 days old female child got admitted with

• cyanosis
• respiratory distress since birth
• Hyperoxia test – Positive 

Diagnosed as D-TGA with ASD

Immediately the patient was treated with Balloon atrial septostomy

Corrective surgery

• Then the patient was sent abroad for final corrective surgery with in 1 months of age.
• Arterial switch operation was done on 25 Aug 2017 in Jaypee Hospital, India

 

Baby born with cardiac problems are increasing alarmingly …………

• Neonatal ICU in every hospitals are trying to incorporate neonatal cardiac care in respective  hospitals.

INTRODUCTION

• Expanded availability of prenatal diagnosis and assessment, increased accuracy of genetic analyses and counseling have made it possible to alert families and caregivers to the possibility of a newborn born with cardiovascular compromise.
• Unfortunately despite the increasing sophistication, precision and availability of methods of detection, only 1% of all complex cardiac malformations in viable fetus are detected before acute clinical presentation.

Background

• In Armed Forces Hospital neonates comprises 15% of all echocardiography carried out in NIC lab. The commonest CHD in neonate in our country is atrial septal defect followed by PDA and VSD.

• In other hospitals, neonate comprises 10-12% of all echocardiography in the outpatient department.

Table-I

The frequency of congenital heart disease among hospital live birth (2004-2006).

Table-II

Percentage of positive Echocardiographic findings in suspected newborn and newborn for screening
(In CMH ECHO LAB) 2004-2006

Table-III

Percentage of newborn echo in Lab Aid Cardiac Hospital in Ped lab 2009

Percentage of newborn echo in Lab Aid Cardiac Hospital ( Ped lab) from  2009 to 2017

Incidence

Awareness  created

• Recently there has been an increasing awareness of the importance of early referral of newborn infants with heart disease to special centers.
• The ease and safety of transport in new ventilator incubators has encouraged this transfer.
• Early referral, improvement of diagnostic methods, medical management, catheter intervention, and surgical treatment have further improved the outcome of congenital heart diseases.

Treatment facilities: Newborn

Very  limited !

Many Newborn of our country are dyeing from CHD before reaching pediatric cardiologist/ Surgeons. Even if they are reaching to a center, they are not getting interventions /surgeries in time as they are available in one or two places or not available at all. Some of them needs treatment from abroad.

 

MANIFESTATIONS OF CHD IN NEWBORN

Observation

• Cyanosis,
• Respiratory distress,
• Peripheral desaturation,
• Behavioral abnormality and less activity

Palpation

• Thrill
• Poor perfusion
• Hepatomegaly

Auscultation

• Abnormal heart sounds
• Murmurs & bruits.

HOW TO DIAGNOSE

• A. Clinical suspision

  – Cyanosis

  – Respiratory distress

  – Lathergy

  – Hypoperfusion

  – Shock

• B. Investigation

  – Hyperoxia test

  – CXR

  – ECG

  – Echo

  – Blood gas analysis

CARDIAC EMERGENCIES: CYANOTIC -CHD

Commonest in the first week of life.

•  Hypoplastic left heart syndrome
•  Transposition of Great Arteries
•  Pulmonary atresia or severe pulmonary stenosis
•  Total anomalous pulmonary venous drainage
•  Tricuspid Atresia
•  Ebstein Anomaly

CARDIAC EMERGENCIES: HEART FAILURE

• Hypoplasia of the left heart.
• Coarctation of Aorta.
• Severe Aortic Stenosis
• Persistent Truncus Arteriosus.
• Double Outlet Right Ventricle
• Complete A-V canal defect
• Cortriatiatum.
• Large A-V fistula

CARDIAC EMERGENCIES: MURMURLESS HEART

Cyanotic	A cyanotic
TGA TAPVD HLHS PA	CoA Cortriatriatum Myocarditis Single ventricle ALCAPA

MURMURLESS OTHER EMERGENCIES

Persistent fetal circulation (PFC):

• PA Pressure high
• Rt to Lt shunt through ASD and PDA
• Infant presents with cyanosis, respiratory distress.
• H/O Perinatal Asphyxia present.
• Difficult to diagnose by Echocardiography and often missed by inexperienced Echo cardiographer
• Mortality 25-30%if not treated.

MURMURLESS OTHER EMERGENCIES

Persistent Pulmonary Hypertension (PPHN):

• PA Pressure high
• Lt to Rt shunt through ASD and PDA
• Infant presents with cyanosis, respiratory distress.
• H/O Perinatal Asphyxia may not present.
• Difficult to diagnose by Echocardiography and often missed by inexperienced Echo cardiographer
• Mortality 25-30% if not treated.

MURMURLESS OTHER EMERGENCIES

Transient myocardial ischemia

• H/O Perinatal Asphyxia present
• Myocardial glycogen reduced
• Present with cyanosis, respiratory distress, hepatomegaly.
• Shock in severe case.

DO NOT FORGET

• Neonatal Hypocalcaemia (cause of heart failure)
• Systemic Arteriovenous fistula
• Arrhythmias in newborn: SVT, Complete heart block.
• Severe anemia, hypoxia, hypoglycemia

PROBLEMS ASSOCIATED WITH HAEMODYNAMICS AND MITABOLIC BALANCE

• Hypotension
• Desaturation
• Brady / Tachycardia
• Hypoperfusion
• Hypoxia
• Acidosis
• Hypothermia
• Hypoglycemia / Hypocalcaemia
• Renal failure
• Multi-organ failure

 REFERRAL TO CARDIAC CENTRE / PEDIATRIC CARDIOLOGIST

 Ensure

• Safe transport
• Nutrition
• Ventilation

TRANSPORTATION OF NEWBORN

Transportation is necessary to provide:

• Definitive diagnosis
•    Ongoing medical care
•    Corrective intervention
•    Lifesaving intervention
•    Corrective surgery
•    Treatment of acute deterioration
• Baby should arrive at referral centre in as good a condition as possible.

 

• The following complications must be avoided:
  •   Hypothermia
  •   Acidosis
  •   Metabolic disturbances
  •   Severe hypoxia
• Logistics of transport should be checked properly before a transfer

 TREATMENT OF NEONATAL CARDIAC EMERGENCIES

Medical treatment / General

• Catheter Intervention
•  Surgical Intervention

 Medical Treatment / General

• Care of ventilation

  – Room air

  – O2 Inhalation

  – Artificial ventilation

1. Non invasive

2. Invasive

• Maintenance of Acid base and electrolyte status.

Medical treatment cont

Noninvasive ventilation

• CPAP
• High Flow O2

Care of I/V lines:

  Central

  Peripheral

• Maintenance of intake out put chart
• Care of catheter in ventilated patient
• Skin care
• Care of eye and oral cavity
• Planning for Investigation
• Correction of anemia or any blood component deficiency:

 Whole blood

 FFP

 Platelet

• Nutrition:

  Milk

  TPN

  Fluid

SPECIFIC  TREATMENT

• 

Treatment of heart failure

• Digitalization
• Diuretics

Inotropes

• Dopamine
• Dobutamine
• Adrenaline
• Noradrenaline
• Milrinone
• Isoprenaline

Treatment

TREATMENT of MI

• Digoxin
• Diuretics
• Oxygen/ventilation
• Correction of acidosis /hypoglycemia
• Electrolyte imbalance.

TREATMENT OF PFC

• Pulmonary vasodilators
• Ionotropic
• Digoxin
• Diuretics
• High flow oxygen Therapy

TREATMENT OF PPHN

INTERVENTION FOR CLOSURE OF DUCTUS ARTERIOSUS

• Indomethacin (intravenous 3 doses) ,0.2-0.25 mg/kg/dose 12 hourly in infusion over one hour.
• Ibuprophen (oral 3 doses)10mg/kg/day for 3 days.
• Indication: Isolated PDA in preterm.

INTERVENTION FOR KEEPING THE DUCTUS PATENT

Inj Prostaglandin E1/E2  .01-.1microgram/kg/min

Indication: Ductus dependent cyanotic Cong heart lessons.

DILATED CARDIOMYOPATHY

• Ionotropes
• Diuretics
• Vasodilators

SUPRAVENTRICULAR TACHYCARDIA

SVT

• Digitalization
• Adenosine
• Propranolol
• Esmolol
• DC shock
• 

CYANOTIC SPELL

• Hydration
• Sedation
• Esmolol
• Propranolol, Morphine
• Maintenance of acid base status, hydration
• Intubation
• Urgent B T shunt.

CATHETER INTERVENTION IN NEWBORN

• Balloon atrial septostomy for those with closed circuit circulation TGA, TAPVD, TA, PA, MA
• Balloon valvoplasty

  – Critical PS

  – Critical AS

• Balloon angioplasty for Coarctation of Aorta
• Stenting of PDA for ductus dependent lesion.
• Laser Perforation of  atretic pulmonary valve

Life-Saving intervention

PDA stenting in a newborn Life-saving procedure for PA VSD & PDA

Newborn

Age: 02 days,  Weight: 3 kg

Dis: PA, VSD & PDA

Note: PDA stenting  done under Umbo ventilation, Intubated the baby after a procedure and extubated after  2 days

Name: Lubaba

Age: 15 days, Weight: 3.2kg

Dis: PA, VSD & PDA

Procedure: PDA stenting done 3.5 x 12 mm stent

Life saving PDA device in infant

Name: Nasifa

Age: 2 months, Weight: 2.2kg

Dis: Large PDA with reverse shunt, Severe PHT

Device closure done with 6/6 ADO II device

Life saving PDA device in newborn

CRITICAL AORTIC VALVE STENOSIS

Aortic valvoplasty done both of them

Critical PS Balloon Valvoplasty

Life saving intervention

Name: Rafi

Age: 1 month, Weight: 3.5 kg

Dis: Severe pulmonary valve stenosis

Balloon valvoplasty done 6×3 balloon

Name: Master Sian

Age: 3 months, Weight: 4 kg

Dis: Severe PS

NEONATAL  CoA

Neonatal Balloon Coarctoplasty

Name: Manha

Age: 1.5 month, Weight: 3.4 kg

Dis: severe coarctation of aorta

 

Name: Hafsa

Age: 2.5 months, Weight: 4.5 kg

Dis: Severe coarctation of aorta

Name: Raime

Age: 16 days, Weight: 2.6 kg

Dis: TGA, VSD & PHT

Procedure: Life Saving Septostomy done

PDA LIGATION

BT SHUNT

Statistics of Newborn Catheter Intervention since 1998

Statistics of Pharmacological  Intervention since 1998

CONCLUSION

• The clinical diagnosis of heart disease is more difficult in the newborn period than at any other time, yet a correct diagnosis without delay is essential for effective treatment.
• It is important to stress that the absence of heart murmur dose not rule out heart disease. There may be no heart murmur in some of the most severe, yet operable, cyanotic lesions.
• So diagnosis should be made without delay to save the life of a newborn by doing specific interventions.