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PNEUMOPERICARDIUM associated with air embolism in TTN Baby a Rare cases presentation

Dr. Dinakara Prithviraj, Dr.Manjunath CB, DrVivek Chail, Dr. Aravind N , Dr      Swagata M
Neonatal ICU, Dept of Pediatrics, Dept of Radiology. Vydehi Institute of Medical Sciences and Research Centre. Whitefield, Bengaluru Phone no: 080-28413385-89, Ext-273.
Email-  drdinakar.nishanth@gmail.com, vchail@gmail.com

Key words: TTN=Transient Tachypnea of Newborn, Pneumopericardium, systemic air embolism, MCA= Middle cerebral artery, Cyanosis, Respiratory distress.

20 hours old female baby delivered through LSCS (failure to Progress). Cried immediately after birth needing only suction and stimulation at the time of birth. APGAR 1st = 8, 5th = 9 BWT = 2.5kgs. Noted mild indrawing, grunting, respiratory distress admitted in NICU. Given oxygen by headbox, IVF, empirical antibiotics given, taken chest X ray shows severe TTN.  Gradually Respiratory Rate increased from 60 – 80/m indrawing increasing grunting persisted, needing increment of O2 from 3L – 5L/min.
After 12 hours condition is same. Taken CX-Ray shows same features suddenly SPO2 started fluctuating from 95% to 90-85% at 19 hours of life. Once again taken CX-Ray shows mild pneumopericardium shifted to us for further treatment (during 19 hours to 20 hours of life SPO2 fluctuation increased)

On examination

Full term baby wt=2.5kg, cry –weak, in sever distress.
Central cyanosis, peripherals are blue. Vitals =HR = clinically difficult to monitor shows 186/m with low voltage graph..  RR=99/m with indrawing SPO2 = 25-30% BP=not recordable. CX-Ray = Pneumopericardium with PIE.

Immediately started head box O2 10l/min. Prepared for pericardialcentesis, drained the pneumopericardium by needle aspiration within 30seconds SPO2 improved to 100% cyanosis gradually disappeared.

Removed the needle taken serial chest X-ray over days, shows gradual decrement in pneumopericardium but SPO2 maintained with in normal limits.  Gradually Respiratory Distress settled down.  Indrawing, grunting disappeared .CX-Ray completely became normal

Clinically from 1st day right half of body movements are decreased, next day it is very evident and third day movements are very less.  Done U/S brain shows Hyperechogenic area on left hemisphere.  On Doppler study left MCA (middle cerebral artery) pulsations not seen. Immediately suspected Air embolism. To confirm done MRI brain shows the same pathology.

Baby completely recovered from respiratory distress and pneumo pericardium over 2-4 days septic work ups were normal discharged with advice about physiotherapy.
Followed up every 15days with US brain, first one and half month baby had hemi paresis of RT side of body and regarding this explained about spontaneous recovery. Since parents are very anxious about the baby, I explained about my personal experience of Piracetam syrup usage, taken consent before giving medicine.  After starting that medicine within 15days noted mild collateral pulsations on left hemisphere of brain.
Next 15days complete pulsations in left MCA and good improvement in the movements of Right half of body (tone, reflex).Continued the medicine for total 12 months and followed all developmental milestones and hearing test –all are within normal limit.
Conclusion: - Pnenmopericardium with air embolism together is very rare entity, together occurs only if baby needs vigorous, CPR, high ventilator pressure.  But in our case report baby had simple TTN.  Probably some mucous or fluid might have acted as ball valve mechanism and it ruptured into perivascular sheaths migrated towards hilum to pericardium at the same time some of pulmonary vessels ruptured and air might have entered into systemic circulation.
Regarding using of piracetam it is purely personal experience, Improvement in Air embolism is spontaneous.
It would have been coincidental or piracetam might have increased microcirculation in the infracted brain tissue (further studies needs in this regard).

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This is 1st case PNEUMOPERICARDIUM associated with Air embolism in TTN Baby, reported with this complication and with out any CPR or on ventilator support, in any available neonatal article, web or journal.
References:
  1. Cloherty JP, Eichenwald EC, Stark AR. Pulmonary air leak. Manual of Neonatal Care 6th edn;2008; 352- 357.
  2. Goldsmith JP, Karetkin EH.Pulmonary air leak. Assisted Ventilation of the Neonate 4th edn;2003;192-193.
  3. Gomella TL. Pulmonary Diseases. Lange clinical manual Neonatology 5th edn;2007 ; 524-530.
  4. Martin RJ, Fanaroff AA, Walsh MC. Pneumothoprax and other air-leak syndromes. Diseases of the Fetus   and Infant 8th edn;2006;1128-1138.
  5. Taeusch HW, Ballard RA, Gleason CA. Principles of respiratory monitoring and therapy. Avery’s Diseases of the Newborn 8th edn;2006; 660-664
  6. McIntosh N et al: Clinical diagnosis of pneumothorax is late: use of trend data and decision support might allow preclinical detection. Pediatr Res 2002;48:408
  7. Mansfield PB et al: Pneumopericardium and pneumomediastinum in infanys and children. J Pediatr Surg 1973;8:691.
  8. Bowen FW Jr. Chandra R, Avery BG: Pulmonary interstitial emphysema with gas embolism in hyaline membrane disease. Am J Dis Chld 126:117, 1973
  9. Siegle RL, Eyal FC, Rabinowitz JG: Air embolus following pulmonary interstitial emphysema in hyaline membrane disease. Clin Radiol 27:77,1976

Pneumopericardium with air embolism case report photos


PNEUMOPERICARDIUM

RIGHT MCA PULSATION SEEN
HYPER ECHOGENECITY ON
LEFT HEMISPHERE NOTED

LEFT MCA PULSATION NOT SEEN

AFTER PERICARDIALCENTESIS

MRI BRAIN SHOWS LEFT
HEMISPHERE INFARCTION

LEFT MCA PULSATION SEEN
(RECOVERED)
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