Effusion

Pericardial Effusion - Tamponade

Pericardial effusion. Measurement should be taken in diastole. Tamponade is a diastolic problem, with restrictive filling. Here, the effusion seems circumferential. Not surprisingly, in a newborns that is lying on his back, the effusion collects posteriorly along the posterior wall of the LV. The fluid can be seen in parasternal short and long axis view in this particular case.

Evaluation of restricted filling - PW of RV and LV inflow. 

• Increased tricuspid valve inflow variability on spectral PW-Doppler (normal <40%)

• Increased mitral inflow variability on spectral PW-Doppler (normal <25%)

A good practice is to compress time in order to observe variation in inflow Doppler velocities. This may be altered in individuals that are not spontaneously breathing.

Ref: https://pedecho.org/library/chd/pericardial-tamponade

Measurements should be done at the end of diastole. Here, as outlined by the ECG tracing, just before the P-wave.

Emergency Pericardiocentesis Procedure

Multi-Disciplinary Pediatric Point of care Ultrasound Bootcamp Simulation Scenario 

The crashing neonate

Case shared by Dr Brahim Bensouda from Hôpital Maisonneuve Rosemont 

A newborn presented initially with significant retractions without bradycardia. Dr Bensouda, TnECHO specialist and Neonatologist member of the TnECHO Quebec Collaborative, had done the workshop on pericardiocentesis and had trained through simulation on how to perform this technique at the bedside. A TnECHO was obtained and the images are shared below.

The views above are in the subcostal area showing a large pericardial effusion. There is altered filling and contractility. The heart is moving in the pericardial pocket during contraction. The liquid is anechoic (black appearance). 

Milky pink fluid aspirated by emergency pericardiocentesis. After puncture, it is important to remove the needle from the catheter to avoid puncture of the muscle wall upon re-expansion while draining the pericardial fluid. The fluid should be sent for cytology / cell count (especially for lymphocytes), culture, total protein, LDH albumin level, triglycerides and biochemistry (electrolytes and glucose) - to evaluate if presence of total parenteral nutrition (TPN) fluid and intravenous lipid fluid. In this case, upon fluid drainage, one can see that the heart function is back to normal with adequate filling. A catheter is seen in the right atrium, which has been withdrawn.  The fluid analysis was compatible with extravasated TPN/Lipids.