Cowan Aashana Dhruva, Emelue Ezinwanne Rosemary, Spyropoulos George, Thakkar Mehul, Di Paola Jorge, Glatz Andrew, Rabinowitz Edon J
Department of Pediatrics, Division of Pediatric Critical Care, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110-1093, USA.
Department of Pharmacy, Washington University School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110-1093, USA.
Eur Heart J Case Rep. 2024 Oct 14;8(11):ytae527. doi: 10.1093/ehjcr/ytae527. eCollection 2024 Nov.
Neonatal pulmonary embolism is a rare occurrence, especially when idiopathic, instead occurring in patients with identifiable risk factors including severe dehydration, presence or history of a central venous line, or identifiable genetic causes. Given the rarity of paediatric and neonatal pulmonary emboli, few guidelines exist to support the clinician in both the initial resuscitation and ongoing management of the critically ill patient with pulmonary emboli.
We present a 5-day-old female with unprovoked massive pulmonary embolism and associated haemodynamic compromise. She presented with central cyanosis and weak respiratory effort with hypoxaemia, persistent tachycardia, and hypotension despite initial fluid resuscitation, intubation, and administration of 100% FiO with inhaled nitric oxide. She was ultimately diagnosed with a massive pulmonary embolism involving the right pulmonary artery by both echocardiography and computed chest tomography, initiated on inotropic support and systemic anticoagulation, after which she underwent mechanical thrombectomy. She was successfully extubated soon thereafter, with subsequent resolution of her emboli. No provoking factors were able to be identified for this patient.
This case highlights the cumulative burden of pulmonary obstruction and inter-ventricular interactions that lead to haemodynamic compromise in the event of massive pulmonary embolism, with resultant considerations of key management strategies. These include the risks of fluid resuscitation and introduction of positive pressure ventilation, as well as the need for early consideration of inotropic support and an institutional pathway for anticoagulation, ultimately proposing a multidisciplinary algorithm for the clinician to deploy when faced with impending cardiovascular collapse from massive pulmonary embolism.
新生儿肺栓塞较为罕见，尤其是特发性肺栓塞，多发生于具有明确危险因素的患者，包括严重脱水、存在中心静脉置管或有相关病史，或有明确的遗传病因。鉴于小儿及新生儿肺栓塞罕见，几乎没有指南可支持临床医生对患有肺栓塞的危重症患者进行初始复苏及后续管理。
我们报告一名5日龄女性，患有不明原因的大面积肺栓塞并伴有血流动力学障碍。她表现为中枢性发绀、呼吸微弱、低氧血症、持续心动过速以及低血压，尽管进行了初始液体复苏、气管插管并给予100% 氧浓度及吸入一氧化氮治疗。最终通过超声心动图和胸部计算机断层扫描确诊为累及右肺动脉的大面积肺栓塞，开始给予血管活性药物支持和全身抗凝治疗，之后她接受了机械血栓切除术。此后不久她成功拔管，随后肺栓塞得以缓解。该患者未发现诱发因素。
本病例突出了在大面积肺栓塞时导致血流动力学障碍的肺阻塞累积负担和心室间相互作用，以及由此产生的关键管理策略考量。这些包括液体复苏和引入正压通气的风险，以及早期考虑使用血管活性药物支持和建立机构抗凝途径的必要性，最终为临床医生在面对大面积肺栓塞即将导致心血管崩溃时提出了一种多学科算法以供应用。
