0:01

So this is a four day old infant who has lots

0:04

of abnormalities, as you can tell, by all

0:06

of these life support devices that, um, this patient has.

0:09

So let's go through them one by one

0:11

and try to find the one that's malpositioned.

0:13

So first, this patient is, um, intubated

0:16

with congenital heart disease and is postoperative.

0:18

So there's an open chest. These are epicardial pacing wires.

0:22

We have some penrose type kind of, um,

0:24

like drainage catheters in the superior mediastinum.

0:28

We have an endotracheal tube that I see the tip to the level

0:31

of the proximal one third thoracic trachea.

0:33

We have a right neck, probably internal jugular approach,

0:36

central venous catheter.

0:37

That tip is a little on the high side, um,

0:40

like projecting over the upper SVC region.

0:43

Um, at our institution, they use inner atrial catheters

0:47

to both monitor the patient's right sided heart pressures,

0:50

but also to be able to administer, um,

0:52

medications directly into the right heart.

0:55

This one is malpositioned on purpose.

0:57

So typically in inter atrial catheter, you want the tip

1:00

to be projecting over the right atrium.

1:02

This one is sort of just lying in the anterior chest

1:04

and this is what they, they put them here on purpose

1:07

until they go back in and close the chest.

1:09

So we will expect this inter atrial catheter

1:12

to be mount positioned with the tip not in the right atrium

1:15

until we see sternal wires.

1:18

This patient also has a Blake drain,

1:20

which is this big catheter that curves over the entirety

1:23

of the chest and it looks like there's a vertically

1:26

oriented chest tube as well.

1:27

With the tip projecting over the kind

1:29

of the thoracic inlet level, we have an enteric tube

1:32

with the tip projecting over the gastric body.

1:35

This kind of funky looking sensor here is

1:37

called the nearest sensor.

1:39

That is a near red infra, uh, near,

1:43

if you see this sort of unusual looking, uh, device

1:46

that's actually a sticker placed on the patient's abdomen.

1:49

That's the nearest sensor,

1:50

which is a near infrared spectrometer.

1:53

It, it's just like another pulse oximeter,

1:55

basically looking at the oxygen saturation of the, um,

1:59

of the tissues directly underlying the sensor.

2:02

Then we have not only a, a bladder catheter,

2:04

but we have a rectal temperature probe.

2:06

Um, and then last but not least,

2:08

we have some umbilical catheters.

2:09

So this one that goes,

2:11

that extends from the umbilicus inferiorly into the iliacs

2:14

and then courses up to the abdominal aorta

2:16

with a tip in the thoracic, um,

2:19

descending thoracic abdominal aorta.

2:20

That's the UAC, it looks appropriately configured,

2:24

but this one is the umbilical venous catheter.

2:26

So it enters directly from the umbilicus, goes

2:29

through the umbilical vein.

2:31

And this tip is low lying.

2:33

This has not yet reached the level

2:34

of the left portal vein confluence.

2:37

So we have a low lying left portal vein.

2:40

Uh, we have a low lying umbilical vein, um,

2:44

with the tip near the confluence with the left portal vein,

2:47

but, uh, low lying in position.

2:49

So this is the most important finding in this,

2:51

this postoperative infant.

2:53

Don't get distracted

2:54

by the billion support devices in these post, um,

2:57

postoperative, especially congenital heart disease

3:00

kids postoperatively.

3:02

Go one by one.

3:03

Um, and just make sure each

3:04

and every little catheter looks like

3:06

it's in an okay position.

3:08

This patient later that same day underwent abdominal

3:11

ultrasound, um, for a separate reason.

3:14

And so, uh, uh, this patient was imaged with doppler

3:18

to ensure vascular patency.

3:20

So, uh, we have nice normal antegrade flow

3:22

of our main portal vein.

3:24

It's going the same direction as the adjacent artery,

3:26

which which we caught on the same plane.

3:28

Um, pulcitile flow in the main portal vein is okay in a

3:32

newborn, especially with congenital heart disease.

3:34

We have some normal, uh, main hepatic artery, uh,

3:38

spectral waveforms.

3:39

The right portal vein is patent.

3:41

It has some, uh, uh, some ity,

3:44

but we are, we have antegrade flow in

3:46

that portal vein going from the portal hetus

3:50

with blood directed into the liver parenchyma.

3:53

We have a normal hep right hepatic arterial waveform.

3:57

We do have patent hepatic veins.

4:00

We're noting just a little bit

4:01

of simple ascites in the peri

4:02

hepatic region of this patient.

4:05

This patient had, um, has a history

4:07

of hypoplastic left heart syndrome on

4:09

his status post Norwood.

4:10

And increased bidirectional flow

4:12

of the hepatic veins is a direct reflection

4:15

of what's going on in the right atrium

4:17

of this, of this patient.

4:18

So we're, we're seeing some increased, uh,

4:21

bidirectional flow at the level of the hepatic veins.

4:24

Um, our middle and left hepatic veins should show us similar

4:28

increased ity

4:29

or increased, uh, bidirectional flow of both

4:32

of those, um, veins.

4:34

Our upper abdominal IVC is nice

4:36

and patent with the waveform show there.

4:39

We're moving on to, uh, some gray scale images.

4:43

Um, with attention to the right hepatic lobe.

4:45

We have sludge in this gallbladder,

4:47

which is also thick walled, um,

4:49

in this infant almost always, that is secondary in nature.

4:55

Um, uh, we have no extra hepatic biliary ductal dilatation,

4:59

and of course we didn't see any intra hepatic

5:01

ductal dilatation as well.

5:03

And then we're gonna move over

5:03

to the left side of the liver.

5:05

I think this patient had some abdominal bandages.

5:07

We saw all of those life support devices,

5:09

including those chest tubes with the bandage, kind

5:11

of obscuring our acoustic windows

5:13

or limiting our acoustic windows.

5:14

So now we're focusing on the left side of this patient.

5:17

And this is, um, the reason for including this, uh,

5:20

this example in this, um, in this series.

5:23

And that is we see some left hepatic artery having some, uh,

5:26

power doppler fill in here.

5:28

But there's this other structure right next

5:30

to the left hepatic artery that has no flow in it

5:33

and it has some, uh, echogenic material within the lumen.

5:37

Um, we have multiple images of the tech trying to get this,

5:41

this structure to fill in with color flow unsuccessfully.

5:45

And so, um, and here's a spectral image showing

5:48

that there's like no actual flow within

5:51

this left portal vein.

5:52

So this is one of the most common things

5:54

that we see in the setting of an umbilical

5:57

Venous catheter, and that is left portal vein thrombosis.

6:01

Um, so we will, uh,

6:03

describe left portal vein thrombosis talk about whether it

6:05

looks acute versus not acute.

6:07

This patient is only four days old

6:09

and this looks expansile and somewhat echogenic.

6:11

So an acute left portal vein thrombosis.

6:14

Um, over time, if this becomes chronic,

6:18

the clot will become small, we'll calcify, um, as it comes,

6:21

becomes fibrotic in some infants.

6:24

Uh, there will be left lobe of the liver atrophy as a result

6:28

of this left portal vein thrombosis.

6:30

So, um, when we will see these patients

6:32

for follow-up imaging, we'll just make sure that we, uh,

6:35

number one is, is the clot still there

6:37

or is it resolving on anticoagulation therapy?

6:40

And then number two, is the left lobe

6:42

of the liver becoming atrophic

6:44

or does it look like it's, uh, preserved in caliber?

6:47

So I'll compare it to prior studies what the morphology

6:49

of the left hepatic lobe looks like.

6:52

We're continuing on with our protocol just showing

6:54

that the pancreas was normal

6:55

and our splenic vein is patent, um, both, uh,

6:58

near the pancreatic head

6:59

or, uh, near the, um, um, uh, Porto splenic confluence

7:03

and at the level of the body.

7:05

And here we're just looking at,

7:06

there is ascites in this infant is a little bit complex

7:09

with these little level internal echoes in this, um,

7:12

acidic fluid here present in the pelvis, uh, of this patient

7:15

with congenital heart disease, probably related to the, uh,

7:19

uh, congenital heart disease itself.

7:21

Not a primary abnormality of the bowel

7:23

or right lower abdominal quadrant,

7:25

but we would also describe that

7:26

and ask our colleagues to correlate

7:28

with the abdominal status of this patient.

7:31

So left portal vein thrombosis related to that, um,

7:35

low lying umbilical venous catheter in this, um, patient

7:38

who is postoperative from congenital heart disease repair.