The Role of POCUS and Monitoring Systems during Emergency Pericardial Effusion in the NICU.

Central venous catheterization is, now, one of the most routinely used procedures in the NICUs, helping during the care of very sick infants. Pericardial effusion is a very rare but severe complication, with a high mortality. The cases described are part of an ongoing retrospective study where the use of central catheters inserted in our surgical NICU, and its complications is being analyzed. 16 cases over 13 years are presented in this article, varying in severity from mild, self-resolving cases that were discovered during routine cardiac POCUS to cases with important hemodynamic impact associated with cardiac tamponade and cardiac arrest. Due to immediate intervention, only one of the cases led to catheter-related mortality and that was under particular conditions. Our aim is to highlight the severity of this complication, the importance of early intervention, and the impact of a highly technologized unit and widely available cardiac POCUS.

Intermittent High-Dose Vitamin D3 Administration in Neonates with Multiple Comorbidities and Vitamin D Insufficiency.

BACKGROUND: Neonates have an increased risk of vitamin D insufficiency due to the inadequate supplementation of mothers and infants after birth. Insufficiency of vitamin D is frequently detected in critically ill patients and is associated with disease severity and mortality. There is yet to be a consensus on the appropriate regimen of vitamin D3 supplementation in high-risk infants. AIM: The main objectives of this study were to determine the prevalence of vitamin D insufficiency in neonates with severe comorbidities and to evaluate whether high-dose vitamin D3 oral administration leads to normal plasmatic concentrations without side effects. METHODS: The current study was a randomized, prospective trial of 150 patients admitted to the Neonatal Intensive Care Unit (NICU) at Maria Sklodowska Curie Emergency Children's Hospital in Bucharest. Patients were divided into three subgroups based on the chronological order of their admission date. Each subgroup received a different pharmaceutical product of vitamin D3. We administered a dosage of 10,000 IU/kg of vitamin D3 orally in three steps, as follows: at admission, one week after admission, and one month from the first administration, targeting a serum 25-hydroxyvitamin D concentration of at least 40 ng/mL. RESULTS: Most neonates (68%) achieved an optimum vitamin D level after one month, even though only 15% of patients had an optimum concentration at admission. After the first high dose of vitamin D3, there was a 27% increase in the mean vitamin D plasmatic level compared to admission levels. However, after one month, the concentrations decreased in all subgroups due to the gap of three weeks between the last two administrations. CONCLUSIONS: An intermittent, weekly high-dose vitamin D3 oral administration leads to a steadier increase and normalization of vitamin D concentration in most critically ill neonates. However, high-dose vitamin D3 administered orally after three weeks decreases vitamin D levels in this high-risk population.

Congenital High Airway Obstructive Syndrome (CHAOS) Survival of a Newborn with Laryngeal Atresia.

Congenital high airway obstructive syndrome (CHAOS) is a rare congenital anomaly, frequently caused by laryngeal or tracheal atresia, tracheal stenosis, and obstructing laryngeal cysts. This is a congenital malformation, often fatal, with an unknown prevalence. Laryngeal atresia is the most frequent cause. We report a case of an intrauterine diagnosis of CHAOS and ascites in a 17-week fetus delivered at 38 weeks of gestation without other associated malformations. A fetoscopic procedure was performed at 22 weeks of gestation. An attempt was made to perforate the affected area to ensure pulmonary fluid circulation and the ascites' resolution. After birth, a tracheostomy was performed. The patient was mechanically ventilated until 11 months of age, when she was discharged with no cerebral or other complications of immediate postnatal anoxia or episodes of respiratory arrest. A laryngotracheoplasty was performed at 2 years old, but decannulation was not possible due to certain complications. At 5 years old, a new surgical intervention was performed, which allowed decannulation 6 months later.

Avoiding High Pressure Abdominal Closure of Congenital Abdominal Wall Defects-One Step Further to Improve Outcomes.

The main goal of surgical treatment for gastroschisis and omphalocele is the reduction of viscera in the abdominal cavity and closure of the abdomen, but the challenge is to succeed without the detrimental effects of increased intraabdominal pressure. In this regard, we performed a retrospective study for all patients admitted for gastroschisis and omphalocele to the Neonatal Intensive Care Unit of 'Marie Sklodowska Curie' Emergency Clinical Hospital for Children, from January 2011 until June 2021. Our aim was to highlight the presence of postoperative abdominal compartment syndrome. We observed that six out of forty-seven patients developed clinical signs of abdominal compartment syndrome, five associated with primary closure and one with staged closure with a polyvinyl chloride patch. Following the results, we decided to implement the trans-bladder measurement of intraabdominal pressure to avoid closing the abdomen at pressures higher than 10 mmHg in order to prevent the development of abdominal compartment syndrome. We consider that there is still place for the improvement of congenital abdominal wall defects management and that the measurement of intraabdominal pressure might help us reach our goal.

Consistent Correlation between MTHFR and Vascular Thrombosis in Neonates-Case Series and Clinical Considerations.

BACKGROUND: MTHFR polymorphism has been inconsistently linked to thrombotic events-some studies have shown its contribution to venous thrombosis, arterial thrombosis, and ischemic stroke, whereas others have found no statistically significant correlation between them. METHODS: A descriptive case series study was performed in the Neonatal Intensive Care Unit of "Marie Sklodowska Curie" Emergency Clinical Hospital for Children in Bucharest, Romania. RESULTS: All patients had positive results for MTHFR variants; 14 patients were positive for compound heterozygosity, 13 patients for MTHFR C677T (seven of which were homozygous), and 13 patients for MTHFR A1298C (three of which were homozygous). Eighteen patients received anticoagulants (heparin, enoxaparin, or bivalirudin), and thrombolytics (alteplase) were administered in six cases. In one case, a thrombectomy was performed; in another, vascular plasty was undertaken. Only in six cases was complete revascularization possible. Incomplete revascularization occurred for one patient with a negative outcome. CONCLUSION: The particularity of this case series is that every patient in our unit who developed thrombi had a positive genetic result for MTHFR mutations. MTHFR mutations should be regarded as a thrombotic risk factor for critically ill patients, and screening for MTHFR mutations should be performed in every admitted patient to intensive care units, thus achieving the prevention of thrombi.

Contrast-Associated Acute Kidney Injury Requiring Continuous Renal Replacement Therapy in A Neonate with Aortic Stenosis-A Case Report.

BACKGROUND: Acute kidney injury occurs commonly in the Neonatal Intensive Care Unit and is associated with increased mortality and morbidity. We report a case of a neonate with congenital heart disease who developed acute kidney injury after cardiac surgery, administration of iodinated contrast media for cardiac catheterization, and a combination of nephrotoxic drugs. CASE REPORT: A term neonate without a prenatal diagnosis of congenital heart disease and with a good postnatal transition was transferred at 13 days of life to the MS Curie Emergency Hospital for Children, Newborn Intensive Care Unit, from a regional hospital where he was admitted at 10 days of life with severe general status, respiratory distress, cyanosis, and arterial hypotension. The cardiac ultrasound detected critical aortic valve stenosis, hypoplastic descending aorta, acute heart failure, and pulmonary hypertension. The patient was intubated and mechanically ventilated and received antibiotherapy (meropenem, vancomycin, and colistin), inotropic and vasoactive support (epinephrine, norepinephrine, dopamine, and milrinone), and diuretic support (furosemide, aminophylline, and ethacrynic acid). A balloon aortic valvuloplasty was performed several hours after admission, but after two days the patient required reintervention by open heart surgery due to relapsing severe aortic stenosis. He developed oligo-anuria, generalized edema, and altered renal function tests on the second postoperative and fourth day post-contrast media administration. Continuous renal replacement therapy was initiated for 75 h, leading to almost instant improvement in blood pressure, then diuresis and creatinine levels. The patient required long-term treatment for heart, respiratory, and liver failure. He was discharged at almost four months of age with normal renal function tests, blood pressure, and good urine output without diuretic support. The literature review indicates that contrast-associated acute kidney injury (CA-AKI) requiring continuous renal replacement therapy is rare. CONCLUSIONS: Our current case proves that iodinated contrast media administration in a neonate with concomitant insults, such as cardiac surgery for a specific pathology, aortic stenosis, coarctation, arch stenosis, arterial hypotension, and administration of nephrotoxic drugs, may lead to severe kidney injury.

Impact of Bedside Balloon Atrial Septostomy in Neonates with Transposition of the Great Arteries in a Neonatal Intensive Care Unit in Romania.

(1) Background: Transposition of the great arteries (TGA) is the most common congenital heart disease, accounting for 5-7% of all cardiac anomalies, with a prevalence of 0.2-0.3 per 1000 live births. (2) Aim: Our main objectives were to evaluate the clinical safety of balloon atrial septostomy in neonates and the possible complications. Furthermore, we tried to establish whether the procedure should be performed in all TGA patients with small atrial septal defects, regardless of oxygen saturation, within a center where corrective surgery cannot be performed on an emergency basis due to the lack of a permanent cardiac surgery team for arterial switch surgery. (2) Methods: We conducted an observational, retrospective, single tertiary-care center study between January 2008 and April 2022, which included 92 neonates with TGA transferred to our institution for specialized treatment. (3) Results: The median age at the time of the Rashkind procedure was four days. The rate of immediate complications after balloon atrial septostomy (BAS) was high (34.3%), but most were transient (metabolic acidosis and arterial hypotension-21.8%). Twenty patients with TGA managed in our hospital underwent definitive and corrective surgical intervention (arterial switch operation) at a median age of 13 days. Most patients (82.6%) were term neonates, but 16 were born preterm. (4) Conclusions: Urgent balloon atrial septostomy is often the only solution to restore adequate systemic perfusion. Bedside balloon atrial septostomy is a safe, effective, and initial palliative intervention in neonates with TGA, which can be performed in the neonatal unit.

Gemella sanguinis Infective Endocarditis-Challenging Management of an 8-Year-Old with Duchenne Dystrophy and Undiagnosed Congenital Heart Disease: A Case Report.

Congenital heart disease (CHD) remains a predisposing cardiac condition for infective endocarditis (IE). Case report: We present the case of 8-year-old boy with no known pre-existing cardiac disease diagnosed with infective endocarditis (IE) with Gemella sanguinis. After admission, he underwent transthoracic echocardiography (TTE), which revealed the presence of Shone syndrome with a bicuspid valve, mitral parachute valve and severe aortic coarctation. He developed a paravalvular aortic abscess with severe aortic regurgitation and left ventricle (LV) systolic dysfunction for which he required a complex surgical intervention after six weeks of antibiotic treatment, consisting of Ross operation and coarctectomy, with a complicated postoperative course, cardiac arrest and ECMO support for five days. The evolution was slow and favorable, with no significant residual valvular lesions. However, persistent LV systolic dysfunction and increased muscle enzymes required further investigation to establish a genetic diagnosis of Duchenne disease. As Gemella is not considered a frequent pathogen of IE, no current guidelines refer specifically to it. Additionally, the predisposing cardiac condition of our patient is not currently classified as "high-risk" for IE; this is not considered an indication for IE prophylaxis in the current guidelines. Conclusion: This case illustrates the importance of accurate bacteriological diagnosis in infective endocarditis and poses concerns regarding the necessity of IE prophylaxis in "moderate risk" cardiac conditions such as congenital valvular heart disease, especially aortic valve malformations.

Neonatal Brain Abscess with Serratia marcescens after Intrauterine Infection: A Case Report.

Brain abscesses are a possible complication of bacterial sepsis or central nervous system infection but are uncommon in the neonatal period. Gram-negative organisms often cause them, but Serratia marcescens is an unusual cause of sepsis and meningitis in this age group. This pathogen is opportunistic and frequently responsible for nosocomial infections. Despite the existing antibiotics and modern radiological tools, mortality and morbidity remain significant in this group of patients. We report an unusual unilocular brain abscess in a preterm neonate caused by Serratia marcescens. The infection had an intrauterine onset. The pregnancy was achieved through assisted human reproduction techniques. It was a high-risk pregnancy, with pregnancy-induced hypertension, imminent abortion, and required prolonged hospitalization of the pregnant woman with multiple vaginal examinations. The infant was treated with multiple antibiotic cures and percutaneous drainage of the brain abscess associated with local antibiotic treatment. Despite treatment, evolution was unfavorable, complicated by fungal sepsis (Candida parapsilosis) and multiple organ dysfunction syndrome.

Pulse Wave Velocity as a Marker of Vascular Dysfunction and Its Correlation with Cardiac Disease in Children with End-Stage Renal Disease (ESRD).

One of the main markers of arterial stiffness is pulse wave velocity (PWV). This parameter is well studied as a marker for end-organ damage in the adult population, being considered a strong predictor of major cardiovascular events. This study assessed PWV in children with chronic kidney disease (CKD) as a marker of cardiovascular risk. We conducted a prospective observational single-center cohort study of 42 consecutively pediatric patients (9-18 years old) with terminal CKD and dialysis, at the Hemodialysis Department of the "M. S. Curie" Hospital, Bucharest. We measured PWV by echocardiography in the ascending aorta (AscAo) and the descending aorta (DescAo), and we correlated them with left ventricular hypertrophy (LVH). Fifteen patients (35.7%) presented vascular dysfunction defined as PWV above the 95th percentile of normal values in the AscAo and/or DescAo. Cardiac disease (LVH/LV remodeling) was discovered in 32 patients (76.2%). All patients with vascular damage also had cardiac disease. Cardiac damage was already present in all patients with vascular disease, and the DescAo is more frequently affected than the AscAo (86.6% vs. 46.9%). Elevated PWV could represent an important parameter for identifying children with CKD and high cardiovascular risk.

Prostaglandin e1 on infradiaphragmatic type of total anomalous pulmonary venous connection - a case report.

We present the case of a newborn with severe pulmonary hypertension, diagnosed with infradiaphragmatic type of total anomalous pulmonary venous connection (TAPVC). The onset was in the first 10 days of life. Diagnosis was made by echocardiography and AngioCT. The pulmonary venous collector was surgically implanted into the left atrium in Germany, but the next month after surgery he developed cardiopulmonary insufficiency and died several days later. We would like to emphasize the importance of prostaglandin E1 administration in this particular case of infradiaphragmatic type of TAPVC and its usefulness in patient's stabilization until surgery. The prognosis in TAPVC, infradiaphragmatic type, is poor and is related mainly to the existence of pulmonary venous obstruction.