Giovanna Fontanelli, Roberto Cimellaro

Neonatal Intensive Care Unit
Bianchi-Malacrino-Morelli Hospital, Reggio Calabria

INTRODUCTION

The Authors describe a case of pulmonary hemorrhage in a premature neonate who, in addition to receiving conventional treatment (concentrated erythrocyte and plasma transfusions, vit. K, mechanical ventilation with high pressure levels), also received surfactant treatment, leading to the clear resolution of the pulmonary hemorrhage situation.

CASE STUDY

Little D. S. F. is an outborn infant. He was delivered by urgent Cesaerian section, due to maternal problems, in the 31^st week of pregnancy weighing 2.000 g. at birth. He was transferred to our Unit approximately 20 minutes after birth due to respiratory syndrome. On arrival, his clinical conditions were so poor - severe respiratory insufficiency and radiological results showing 3^rd degree interstitial lung disease – that intubation and administration of surfactant at dose of 200 mg/Kg were required. He was then placed under flow-synchronized ventilation. On the 2^nd day of life, an unexpected decline in pulmonary function took place with the O₂ requirement increasing to 100 % (starting from 30 %) and extremely serious mixed acidosis (pH 6.98; pO₂ 16; pCO₂ 77.9; BE - 12.7; HCO₃ 18 8; Sat O₂ 39 %; CVO sample). Large quantities of bright red blood flowed out of the O-T cannula and the infant was in a state of extreme agitation, with severe shock and non measurable levels of arterial pressure.

Coagulation was exceedingly altered: PT 65.4; INR 5.74; PTT 78. 7 Ratio 2.89; Fibrinogen 296.
Ventilatory parameters were immediately adjusted, by increasing PEEP and PIP, and the patient was administered isogroup plasma, vit. K, sodium bicarbonate and then surfactant at a dose of 200 mg/Kg, followed by a dose of 100 mg/Kg. three hours later.
From the radiological point of view the initial picture presenting widespread opacification of both lung fields improved, with a clear, progressive reduction of the opacification, as demonstrated by the two radiographic examinations performed subsequent to the administration of the surfactant.

The patient was then monitored from the gas-analytic point of view, and ventilatory parameters and bicarbonate dosages were duly adjusted. After approx. seven hours, acceptable hemogas levels were obtained, even though the O₂ requirement was still at 100 % (pH 7.31, pO₂ 64, O₂ sat 89.6 %, CO₂ 51.2, EB - 0.1, HCO₃ 26.3 arterial sample).

Pulmonary function gradually improved, leading to the child’s extubation 4 days later. A N-CPAP treatment regime was then established for a further three days, followed by an O₂ hood treatment for approx. two days.

On the 10^th day of life (treatment with the oxygen hood had been suspended a few hours earlier) the neonate presented with an episode of severe hematemesis accompanied by a gradual but constant worsening of respiratory activity, manifesting dyspnea and an increased O₂ requirement, symptoms that failed to improve even when N-CPAP treatment was re-initiated The child had to be intubated and during this manoeuvre large quantities of blood flowed out of the laryngeal orifice. After scrupulous aspiration of the cannula, surfactant was administered at a dose of 100 mg/Kg and the neonate was placed under mechanical ventilation with high pressure levels and FiO₂ at 100 %.

The hemogas analysis performed on the arterial sample showed severe metabolic acidosis ( pH 7.08, pO₂ 71, pCO₂ 36.2, O₂ sat. 86 %, EB - 16.5, HCO₃ 10.9). The chest X-ray showed marked hypodiaphaneity of both lung fields. FiO₂ was reduced to 60 % in the course of the 12 hours that followed. A further transfusion with plasma and concentrated red cell solution was performed. In fact hemocoagulative activity was abnormal, although to a lesser degree than that of the previous episode (PT 18, INR 1.5, PTT 47, Ratio 1.8, Fibrinogen 43, ATIII 78.9 %, D-Dimeri 0.36) and a decrease in Ht from 46 % to 10% was observed. These parameters were promptly corrected.

The clinical picture was further complicated in the hours that followed by the onset of sepsis, which made it necessary to continue mechanical ventilation for ten days, notwithstanding the lung improvement evident from the X-rays and the drop in the O₂ requirement.
In fact, the radiographic check-up carried out shortly after the administration of the surfactant revealed a marked reduction in the hypodiaphaneity, which was further confirmed at subsequent check-ups.

Hypofibrinogenemia and hypoalbuminemia remained, accompanied by significant edema and this problem was treated with plasma, albumin and diuretics. The infant's recovery was, therefore, extremely slow; additionally, he was also affected by anaemia and a residual respiratory insufficiency characterized by hypoxemia, reason for which we continued with the oxygen hood treatment, combined with and aerosolized diuretic and cortisone treatment and physiokinesitherapy up until the 38th day of life, at which point he had been weaned off his O₂-dependency.

Unfortunately, the hemorrhage was not limited to the lung but also occurred in the brain, as documented by the cerebral transfontanellar ultrasonography carried out approximately two weeks after the second pulmonary hemorrhage episode (LVs visible, symmetrical, with slightly irregular margins at the plexus and trigon which appear, in turn, to have a slightly irregular outline – past hemorrhage? - Bilateral periventricular hyperechogenicity, more marked in the area of the frontal horns and trigons. Moderate cerebellar hyperechogenicity, 3^rd and 4^th ventricle within normal limits. Cavum vergae). The EEG examination, performed before the patient was discharged, revealed abnormal electrical activity for the age of the patient. The child was discharged on the 55^th day in fairly good general conditions, but the extent of the neurological impairment became clearer at subsequent follow-ups.

CONCLUSIONS

REFERENCES

1. Il Surfattante nella Patologia Respiratoria Acuta" Editor Nicola Dirozzi, Daniela Perrotta. Edizione fuori commercio Riservata ai Sigg.Medici SEEd srl in collaborazione con Chiesi Farmaceutici.

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