Title : A case report of full term newborn with large intracranial hemorrhage surviving complex interventions of craniectomy and acute peritoneal dialysis in the neonatal period
Abstract:
In the Philippine Pediatric Society Registry, there were 27 cases of Intracerebral with Intraventricular hemorrhage and 8 cases of Acute Kidney Injury with Acute Tubular Necrosis under 28 days of age from 2006-2022 that were discharged. However, there were no data on procedures such as surgical intervention nor renal replacement therapy for such cases respectively. In our institution, this patient was the youngest newborn patient who underwent Craniectomy and Peritoneal Dialysis but its use among newborns would require careful review of all clinical aspects and prognosis of the patients to arrive at a decision ensuring that the benefit would outweigh the risk. This is an interesting case of a Full-term 38 weeks female newborn, 2950 grams, born with meconium-stained amniotic fluid indicative of intrauterine fetal distress which resulted in complex conditions requiring interventions rarely done in newborns in our set-up. Further, the patient presented with signs of respiratory distress which are not attributable to a pulmonary condition. Rather, these symptoms were referrable to anemia and metabolic acidosis from significant blood loss. Beyond Hypoxic Ischemic Encephalopathy, the patient was diagnosed with Intracranial Hemorrhage (Intracerebral Intraparenchymal Hemorrhage with Subdural and Subarachnoid Extension, Intraventricular Hemorrhage Grade IV) requiring craniectomy for evacuation of hematoma. This was further complicated postoperatively with Acute Kidney Injury Stage 3 from Acute Tubular Necrosis that warranted Acute Peritoneal Dialysis. The patient was likewise detected by Newborn Screening and confirmed with laboratory assays for Congenital Hypothyroidism. Despite the very stormy course at the Neonatal Intensive Care Unit, the patient survived and was discharged on the 52nd day of life. Significant Intracranial Hemorrhage in newborn is a challenge but with prompt detection, careful stabilization and access to quality surgery, even a very invasive surgical intervention for a newborn such as craniectomy can be lifesaving. Craniectomy and Peritoneal dialysis are rarely utilized invasive procedures for a newborn but can be done safely and be life-saving interventions as well as promote better quality of life for asphyxiated newborns complicated with Intracranial Hemorrhage and Acute Kidney Injury.
Audience Take Away Notes:
- This case presented how intrauterine asphyxiating events can lead to Intracranial hemorrhage and progressive kidney injury as the multi-organ damage of significant hypoxia in the very fragile newborn compounds each other.
- The interventions vary according to the severity and in this case, the management warranted extreme procedures such as craniectomy and Renal Replacement Therapy at the age of < 2weeks emphasizing the value of holistic evaluation for such newborns with stormy NICU course. As way ahead, this patient would require close surveillance of a multidisciplinary team of Pediatrician, Neonatologist, Neurologist, Nephrologist, Endocrinologist and Neuro Surgery Service. Once again emphasizing the value of teamwork that paved the way for the survival of this patient.
