Neonatal Vomiting

Morbidity and Mortality

Conference
Paria Wilson, MD
November 20, 2014

Case Presentation

7 week old former 41 week infant

presented from OSH for vomiting and
respiratory failure
PMH: absent R radius, R ear tag
No vertebral, cardiac, swallowing, or
other anomalies per mom. Mom had
normal fetal echo
PSH: circumcision
Immunizations: UTD
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HPI

3 days of NBNB emesis, 5-6x/day

Loose stools x 1 on day of
presentation
UOP x 5 on day of presentation
Was initially improving then looked
like he had trouble breathing at the
mall on day of presentation

HPI

ROS neg for: fever, cough,

congestion, increased WOB
Taken to PMD office on day of
presentation who recommended
pedialyte for hydration
No weight loss noted at PMD office
Mom states being worked up for
Fanconi
4

HPI

En route to ED, mom reported patient

was lethargic and had increased work
of breathing.
Stopped breathing and looked blue
around lips
EMS arrived within minutes, reportedly
breathing around 20x/min, looked pale,
bagged for a few minutes, no chest
compressions
Transferred to Ft. Thomas hospital
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OSH

Afebrile, HR 80
IO placed right tibia
Glucose 53- received D25 bolus
1808: Intubated with a 3.5 uncuffed
ETT with 1.2mg etomidate, 0.1mg
atropine, and 4mg rocuronium prior
to transfer

Whats your differential?

Inborn Error of Metabolism (IEM)

Sepsis
NAT
Cardiac
Video (till RoseAnn MM)

Arrival to ED (1850)

T: 33.7 HR 153 RR 10 BP 87/54 Sats 95%

HENT: NCAT, MMM, pupils 7->5mm bilaterally
Neck: Normal range of motion. Neck supple.
Cardiovascular: Regular rhythm, S1 normal and S2 normal.
Strong brachial and femoral pulses, no murmur heard.
Pulmonary/Chest: Patient intubated, good bilateral breath
sounds, no focal decreased sounds, easy to bag, ETCO2 30s
Abdominal: Soft. He exhibits no distension. There is no
tenderness. There is no rebound and no guarding.
Genitourinary: Penis normal.
Musculoskeletal: Normal range of motion. Absent radius on
the right.
Neurological: sedated and paralyzed
Skin: Skin is warm. Capillary refill takes less than 3 seconds.
No rash noted. No cyanosis. No pallor.
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What workup would you want?

Confirm ETT location with CXR

CBC, blood culture
UA, urine cx
CSF studies
Istat
Renal
Lactate
Ammonia
LFTs
Procalcitonin
Head CT
Resp PCR
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Initial CXR (1904)

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Interventions requested

D10-1/2NS with concern for

metabolic issues
Ceftriaxone

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STS

Initial VBG (1900): 6.8/94/-21

1912: HR on monitor in upper 160s,
request for D10-1/2NS and bolus
1914: PICU consult, say they are busy
and ask us to tap in ED, ask to be texted
istat results, recommend adding vanc
1917: have access, cant get blood,
decision to fem stick
1921: HR now persistently in the 170s
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STS

1925: blood obtained, HR 177, sats

91% but not discussed
Repeat VBG (1927): 7.1/47/-14
Recap: Video
1928: first repeat BP 65/32
1930: PICU called and asked to give
NaHCO3
1932: HR noted to be up to 180s,
discussed giving 20ml/kg
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STS

1936: Video
1939: discussion of lack of movement
for timing of paralytic
1942: fentanyl administered, HR from
180s to 175 thereafter
1945: roc requested
1946: bolus completed, HR 175,
63/30, sats 95%
1938: Recap video
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Labs (1951-2002)

Renal (1930): 137/5 106/15 13/0.4 gluc

271, AG 16
Lactic Acid: 9.5
LFTs: normal
Ammonia: 49
Procalcitonin: <0.1
CBC: 16 > 11/33.7 < 401
Diff: 68% segs, 4% bands, 21% lymphs

UA: pH 6.0, prot 100, small blood,

glucose 500, nitrite & LE neg
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STS

1956: HR 177, BP 47/23, 95%, Video

Patient has been desatting x 5 min,
RT does not communicate although
changes bagging style frequently,
sats drop to 64% before RN
recognizes
2006: 2nd bolus in
2008: HR 173, BP 62/30, 95%,
decision to give 3rd bolus
2015: fentanyl #2 given

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CXR #2 (2017)

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STS

Video: sats dropping again, bagging at

35/10
2022: plan to transition to vent
2026: EKG
2033: On vent at 35/10
2038: PICU eval, HR 171, BP 70/37, 94%,
Video
2045: Bedside subxyphoid view of heart
normal
2050: Transfer to PICU
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EKG

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Course Thereafter

Resp PCR: + rhinovirus

6 hours of echoing led to the diagnosis

1) Infracardiac total anomalous pulmonary venous return

a) Two right-sided and two left-sided pulmonary veins drain to vertical vein; no
significant obstruction seen as individual pulmonary veins enter vertical vein.
b) Vertical vein crosses diaphragm inferiorly and appears to drain to the
hepatic venous system.
c) The vertical vein appears unobstructed along its course with a mean
gradient of 1-2mmHg where it enters the hepatic venous system.
2) Moderate-size ASD, exclusive right-to-left shunting.
3) Small mid-muscular VSD, shunting left-to-right.
4) Moderate right atrial and right ventricular enlargement.
5) Significant interventricular septal flattening throughout the cardiac cycle.
6) Mildly depressed RV systolic function.
7) Normal LV systolic function.

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Course Thereafter

Transferred to CICU at 0400

OR the next day with uncomplicated
repair
Developed pulmonary HTN
afterwards and was discharged home
on lasix and sildenafil
Doing well at cardiology visit on
11/12
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Things we could improve upon

Incorrect gas- CO2 of 94 not

recognized for 10 minutes (ETCO2
23)
BP was not re-cycled till 1928, 40
minutes after patient arrival and
noted to be 69/35
Timing of his sedatives/paralytics at
OSH
Better communication between
RT/MD (3 personnel changes)

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Age of Presentation for Congenital

Heart Disease

First 2 weeks:
LV outflow tract obstruction (Coarct, AS, HLH)
Cyanotic lesions (Transposition, TAPVR, AV canal

malformations, Truncus)

First Month:
Coarct, VSD, PDA, Truncus, complex lesions (DORV)

6 weeks to 6 months
VSD, AV canal malformations, coronary artery

anomalies, Truncus

Over 6 months
VSD, ASD, isolated valvar lesions, small PDA, PAPVR,

coarct
Fleisher and Ludwig: Cardiac Emergencies

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TAPVR

Supracardiac (43%): PV abnormal

vertical vein innominate vein SVC RA
Cardiac (18%): PV coronary sinus RA
Infracardiac (27%): PV portal vein
liver vascular bed IVC RA
Mixed (12%): connections enter at 2+
different level
All types require ASD for mixing
EKG: RA, RV hypertrophy
CXR: may show pulmonary edema
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1. Anomalous vein returning pulmonary venous blood

from the lungs to the SVC
2. Confluence of pulmonary veins behind, but not
connected to the left atrium.
3. ASD allows blood flow to left atrium.
8. Pulmonary venous blood draining through the liver
to reach the IVC and right atrium.

TAPVR

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TAPVR

TAPVRs presentation can be mild if a

large ASD exists
Obstruction:
Supracardiac: vertical vein between L PA

and L mainstem bronchus

Infracardiac: at level of diaphragm or by
liver parenchyma

Blood flow returning to heart

CO
Backup of the pipes = pulmonary
edema

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Signs and symptoms of Obstruction

BP and acid build-up in blood due

to an inability to pump adequate
amounts of oxygen to the body
Cyanosis resulting from both the
mixing of oxygen-rich and oxygenpoor blood in the heart and the lungs
decreased ability to oxygenate blood
Difficulty breathing from fluid in the
lungs
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A word on metabolic

Neurologic (lethargy, coma, seizures)

and gastrointestinal symptoms
(vomiting, diarrhea) are the most
common presentations in an ER
Additional signs include shock,
hypoglycemia, rapid breathing, and
hypothermia

Up To Date: Inborn Errors of Metabolism, Metabolic Emergencies

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A word on metabolic

Labs to consider in metabolic workup

Istat with glucose (ABG is best)
Ammonia
Lactic Acid
Renal profile for AG
UA for ketones, pH, SG
LFTs/Coags if clinical concern

Management is symptomatic
Hyperammonia may need dialysis
Up To Date: Inborn Errors of Metabolism, Metabolic
Emergencies

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