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The transition to breathing for the hydropic infant after birth is a particularly tenuous situation. The delivery room management of hydrops can be a critical period of intervention and a highly intense event with a critically sick infant requiring extensive resuscitation and multiple procedures immediately following delivery.1 The basic principles for resuscitation of high-risk newborns still apply. However, because of the possibility of pleural effusions and ascites in hydrops, the team must be prepared to perform two additional procedures that are not commonly performed by delivery room personnel: thoracentesis and paracentesis. This chapter outlines the overall approach to delivery room management for hydrops and provides detailed descriptions of these two procedures.
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PREPARATION FOR DELIVERY
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Prior to delivery, appropriate counseling of the family may involve discussion of the etiology of hydrops, if known, and the prognosis.2 In some situations, hydrops may be an end-stage process, and comfort care after delivery may be a reasonable alternative to intensive resuscitation. This decision can be made prior to delivery with informed consent of the parents, allowing them to hold the infant soon after birth and to provide comfort. Prognosis in hydrops is dependent on the etiology, although the etiology may be indeterminate in about a quarter of cases. The prognosis can be discussed prior to delivery if time is available.
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If resuscitation is planned, counseling of the parents should involve explaining the procedures that may be carried out in the delivery room. The delivery room will be a busy and intense environment; thus, preparation of the parents may help to relieve some degree of anxiety.
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The makeup of the resuscitation team may vary by institution. Table 68-1 offers a potential delineation of roles that can be modified depending on availability of specific clinical personnel. The expected duties of clinicians may vary by institution, and this table can serve as a template for developing protocols that are more specific. However, it should be noted that the list of tasks is extensive, and a team consisting of at least 5, and possibly more, members is not an unreasonable expectation for this scenario.
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Delivery Room Equipment
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The equipment necessary for delivery room management of an infant with hydrops will include the basic equipment necessary for resuscitation of any high-risk infant, including a radiant warmer, and equipment for intubation and airway management. Furthermore, as the likelihood for volume resuscitation and medications may be high, supplies for umbilical line placement should be readily available. Difficulty with ventilation in hydrops may lead to the need for paracentesis or thoracentesis, and supplies for these procedures should also be prepared. The typical equipment used for these procedures is shown in Figure 68-1. A list of other equipment that may be used in the resuscitation of hydropic infants is provided in Table 68-2.
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As in all neonatal resuscitation, airway and breathing should be the first priority. Assessment and management should generally follow the procedures as described previously. However, there are several special considerations that can complicate management of the airway and ventilation in an infant with hydrops.
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There may be a significant amount of soft tissue edema caused by hydrops that can distort both external and internal anatomy.
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Congenital Airway Malformation
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Congenital Airway Malformation may be a possible etiology of hydrops. Therefore, it is important that a clinician who is skilled in intubation be assigned the task of airway management. A smaller endotracheal tube may be necessary if there is significant edema. If airway abnormalities are expected, involvement of a pediatric otolaryngologist or anesthesiologist in the delivery room may be warranted.
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Asphyxia commonly accompanies hydrops, so meconium may be present at delivery, and intratracheal suctioning may need to be performed in accordance with the Neonatal Resuscitation Program (NRP) guidelines.
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In contrast to a typical resuscitation, a plan to immediately intubate and start positive pressure ventilation is a reasonable approach because mask ventilation may be ineffective as a result of generalized edema and decreased lung compliance. Typical rules of thumb for determining length of endotracheal tube placement may not be reliable because of distortion of anatomy. Thus, placement of the endotracheal tube should be based on visualization of passage of the tube through the vocal cords or postintubation assessment using end-tidal CO2 monitors and auscultation.
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Because there can be significant effusions, higher peak inspiratory pressures may be needed for adequate ventilation due to both the pleural effusions and the possibility of pulmonary hypoplasia. Limiting the use of excessive oxygen has been a growing priority in neonatology. However, if anemia is the cause of hydrops, there may be reduced oxygen-carrying capacity, and increasing the fraction of inspired air (FiO2) more readily than in other scenarios may be reasonable.
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Paracentesis/Thoracentesis
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If resuscitation efforts are not effective despite the usual strategies, thoracentesis or paracentesis may be necessary. The steps for these two procedures are outlined in this chapter.
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The need for circulatory support with volume resuscitation and medications is likely in moderate-to-severe hydrops. When fetal anemia is known to be the cause of hydrops, blood for transfusion can be prepared and should be ready in the delivery room. It is best to use O-negative, cytomegalovirus (CMV)-negative, irradiated, packed red blood cells cross-matched against the mother’s blood. In any case of hydrops, if blood is not readily available in the delivery room, procedures for quick preparation of blood from the blood bank would be prudent. Personnel should be prepared for umbilical venous catheterization and/or blood transfusion.
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Umbilical Vein Catheterization
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In an emergency, umbilical vein catheterization is often the quickest method for establishing vascular access. If the etiology of hydrops is known to be anemia and there is evidence of volume depletion, the patient can receive a blood transfusion prior to obtaining laboratory results.
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Umbilical Artery Catheterization
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If enough personnel and resources are available, umbilical arterial catheterization to facilitate ongoing laboratory collection and blood pressure transduction may be beneficial. It will also allow for quick collection of blood for laboratory evaluation, including obtaining blood gas and hematocrit values. This will also facilitate partial exchange transfusion, which may be ideal in cases of severe anemia without significant volume depletion.
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Myocardial Dysfunction
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Myocardial dysfunction (including heart block and cardiomyopathy) may be present as the primary cause of hydrops or as a result of pericardial effusions. Although delivery room management may not be able to completely address this dysfunction, quick establishment of vascular access for medications may help to assist in optimal resuscitation. Electrocardiographic (ECG) leads will allow for detecting arrhythmias that may require intervention. Furthermore, ECG leads will help provide continuous assessment of heart rate, particularly if pulse oximetry is difficult to interpret because of subcutaneous edema. If cardiac complications (or need for pericardiocentesis) are anticipated, arrangements should be made to have a pediatric cardiology team (as well as an echocardiogram, defibrillator, or pacing equipment) available at the delivery.
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If ventilation is not effective despite intubation and positive pressure ventilation with higher inspiratory pressures, it is possible that pleural or peritoneal effusions may be interfering with ventilation. If this is the case, thoracentesis or paracentesis may be indicated. Deciding which procedure to perform first depends on the history and clinical assessment. If there are known to be large pleural effusions, thoracentesis may be the first step. Based on the relative frequencies of significant effusions in hydrops, paracentesis is often the more likely procedure to be performed first.
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If the abdomen is clearly distended and taut and ventilation is ineffective, paracentesis may be indicated as the first step. The steps for paracentesis are shown in Figure 68-2. The needle should be inserted into the lower right or left abdomen lateral to the rectus muscle to avoid hitting the liver or spleen, which may be enlarged. When fluid begins to flow through the hub of the needle, the catheter can be gently advanced as the stylet is withdrawn. The catheter can then be connected to the tubing, 3-way stopcock, and syringe. Fluid can be withdrawn with a syringe and collected for laboratory testing.
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The purpose of the procedure is not to remove all of the ascites fluid as this may lead to circulatory instability and may ultimately be ineffective. Rather, the goal is to remove a sufficient amount of fluid (approximately 10–20 mL/kg) to assist in easing ventilator management. The amount of fluid to be removed can be based on an assessment of the decrease in abdominal distension/tautness and improvement in clinical status. In addition, usually there is communication between the peritoneal and the pleural spaces, so paracentesis may remove some of the pleural fluid. Once a sufficient amount of fluid has been removed, the catheter can be taped in place and the stopcock turned to the off position to allow later withdrawal of fluid if necessary. If a significant amount of fluid is removed, the tips of previously placed umbilical catheters may move, and their positions should be verified.
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The steps for thoracentesis are shown in Figure 68-3. The intravenous catheter needle is inserted into the fourth or fifth intercostal space at the midaxillary line and directed posteriorly. To avoid the blood vessels and nerves that run just below the rib, the needle should be inserted just above it. When fluid begins to flow through the hub of the needle, the catheter can be gently advanced as the stylet is withdrawn. The catheter can then be connected to the tubing, 3-way stopcock, and syringe. Fluid can be withdrawn with a syringe to alleviate pressure. Note that removal of pleural fluid may not necessarily improve lung function if pulmonary hypoplasia or pulmonary edema is present. If desired, pleural fluid can be collected for laboratory testing, which can include cell count, culture, and estimation of protein content.
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In some cases of hydrops, thoracentesis with a small catheter may not be enough for resuscitation. Furthermore, because of the high pressures required for resuscitation, pneumothorax may be a potential occurrence. Therefore, preparation for chest tube placement for either fluid removal or pneumothorax may be necessary.
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One quick method of chest tube placement utilizes a blunt-tip safety chest tube kit (as illustrated in Figure 68-4). This method is quicker than using a hemostat for dissection into the pleural space and therefore easier to place in the delivery room setting if necessary. First, the fourth or fifth intercostal space at the anterior axillary line is located. The length of chest tube insertion can be estimated by measuring the distance from the apex of the lung to the insertion site. After sterile preparation of the area, a scalpel is used to make a one-eighth to one-quarter inch incision overlying the space. The safety trocar is pushed into the incision and interspace, palpated above the rib. The trocar can be removed as the chest tube is held firmly in place. The tube is then advanced to the estimated length or approximately 3–4 cm for a term infant.
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If the indication for the chest tube is a pneumothorax, the tip should be aimed anteriorly toward the second intercostal space so that the tip will lie at the highest point of the infant’s chest when lying supine. The tube is then connected to a water-seal vacuum drainage system and secured with suture and dressing.
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If the indication for the chest tube is to drain a pleural effusion, the tube can be directed posteriorly. Prior to connection to the vacuum system, a syringe can be used to obtain fluid for laboratory testing if desired. After the infant is stabilized, a chest x-ray should be obtained to confirm proper placement of the chest tube.
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As intense, prolonged resuscitations can often be associated with unintended hypothermia, procedures that allow for relatively easy temperature monitoring and regulation should be implemented. The radiant warmer should be turned on to the maximum heat setting prior to delivery, and if possible, arrangements should be made to optimize the ambient temperature in the delivery room itself. Using a plastic wrap and a chemical warming mattress are other potential considerations. A continuous-temperature probe can be placed to also assist in temperature monitoring and regulation.
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Hypoglycemia may often occur soon after birth in infants with hydrops. Thus, glucose measurements should be obtained, and initiating an intravenous dextrose infusion should be considered as soon as feasible.
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The delivery room management of an infant with hydrops is complex and requires skilled personnel who are appropriately trained in advanced resuscitation techniques. In addition to airway management and circulatory support, the team should be ready to perform additional procedures that may be required in the delivery room, such as thoracentesis and paracentesis. Proper preparation and anticipation of the procedures that may be necessary are essential for optimal resuscitation of an infant with hydrops.
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McMahan
M, Donovan
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S, Mansour
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B, Papageorghiou
A, Calvert
S, Bhide
A. Prenatal diagnosis of non-immune hydrops fetalis: what do we tell the parents?
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